State of North Carolina
Department of the Secretary of State
APPLICATION FOR CERTIFICATE OF WITHDRAWAL
Pursuant to §55-15-20 or §55A-15-20 of the General Statutes of North Carolina, the undersigned corporation hereby applies to the
Secretary of State for a Certificate of Withdrawal and for that purpose submits the following statement.
1. The name of the foreign corporation is:_____________________________________________________________________
2. The corporation is organized under the laws of:_______________________________________________________________
3. The corporation is not transacting business or conducting affairs in the State of North Carolina and surrenders its authority to
transact business or conduct affairs in this State.
4. The corporation revokes the authority of its registered agent to accept service of process and consents that service of process in
any action or proceeding based upon any cause of action arising in the State of North Carolina, or arising out of business
transacted or affairs conducted in North Carolina, during the time the corporation was authorized to transact business or conduct
affairs in North Carolina may hereafter be made on such corporation by service thereof on the Secretary of State.
5. The mailing address to which the Secretary of State may mail a copy of any process served on the Secretary of State pursuant to
the paragraph above is:
City, State, Zip Code_____________________________________________________________________________________
6. The corporation hereby agrees to file a statement of any subsequent change in its mailing address with the Secretary of State.
7. This application will be effective upon filing, unless a date and/or time is specified:________________
This the ______day of ___________________ , 20______
Name of Corporation
Type or Print Name and Title
Filing fee is $25. This application must be filed with the Secretary of State.
P. O. BOX 29622
RALEIGH, NC 27626-0622
(Revised October, 2002)