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Application For Certificate Of Withdrawal Foreign Corporation Form - Connecticut Secretary Of The State

APPLICATION FOR CERTIFICATE OF WITHDRAWAL

FOREIGN CORPORATION

Office of the Secretary of the State

MAILING ADDRESS:

DELIVERY ADDRESS:

Commercial Recording Division

Connecticut Secretary of the State

P.O. Box 150470

30 Trinity Street

Hartford, CT 06115-0470

Hartford, CT 06106

860-509-6003

FEE: Stock $100.00

Non-Stock $40.00

Make Checks Payable To “Secretary of the State”

Space For Office Use Only

1. NAME OF CORPORATION IN ITS STATE/COUNTRY OF FORMATION:

2. IF DIFFERENT FROM THE ABOVE, THE NAME UNDER WHICH CORPORATION TRANSACTS

BUSINESS IN CONNECTICUT:

3. STATE OR COUNTRY OF INCORPORATION:

The corporation is not transacting business/conducting affairs in Connecticut and surrenders its authority

to transact further business/conduct affairs therein.

The corporation revokes the authority of its registered agent to accept service of process on its behalf.

The corporation appoints the Secretary of the State as its agent for service of process and consents to

service of process thereon in any action, suit or proceeding based on a cause of action arising during the

time it was authorized to transact business/conduct affairs in this state.

4. THE ADDRESS TO WHICH THE SECRETARY OF THE STATE MAY MAIL ANY PROCESS SERVED

UPON HIM IN ACCORDANCE WITH THE ABOVE STATED APPOINTMENT:

______________________________________

Number and Street or P.O. Box

______________________________________

City, State and Zip Code

The corporation agrees to notify the Secretary of the State in the future of any

changes to the above stated address.

5. EXECUTION:

Dated this_____________day of _____________, 20_______.

Print or type name of signatory

Capacity of signatory

Signature

R:\CommercialRecording\CRD WEB FORMS\docs\app for cert of withdrwl - foreign corp.DOC

Application For Certificate Of Withdrawal Foreign Corporation Form - Connecticut Secretary Of The State