Form Fcw - Application For Certificate Of Withdrawal With Instructions
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1
2Kentucky Secretary of State
T
G
REY
RAYSON
_________________________________________________________________________________________________
____
Application for Certificate
FCW
Division of Corporations
of Withdrawal
B
F
USINESS
ILINGS
P.O. Box 718
Frankfort, KY 40602
(502) 564-2848
________________________________________________________________________
Pursuant to the provisions of KRS Chapter 271B, 273 or 274, the undersigned hereby
applies for a certificate of withdrawal on behalf of the corporation named below and for
that purpose submits the following statements:
1. The corporation is
a business corporation (KRS 271B).
a nonprofit corporation (KRS 273).
a professional service corporation (KRS 274).
2. The name of the corporation is
______________________________________________________________________.
(Name of corporation or fictitious name adopted for use in Kentucky)
3. The state or country of incorporation_______________________________________.
4. The corporation received authority to transact business in Kentucky on____________.
5. The corporation is not transacting business in Kentucky.
6. The corporation hereby surrenders the authority to transact business in Kentucky.
7. The corporation hereby revokes the authority of its registered agent in Kentucky to
accept service of process on its behalf and hereby appoints the Secretary of State as its
agent for service of process in any proceeding based upon any cause of action arising
during the time it was authorized to transact business in Kentucky.
8. The mailing address to which the Secretary of State may mail a copy of any process
served is
______________________________________________________________________.
Address
City/State
Zip Code
9. The corporation hereby commits to notify the Secretary of State in the future of any
change in the mailing address set forth in #8 (above).
10. This application will be effective upon filing, unless a delayed effective date and/or
time is specified:
____________________________________
(Delayed effective date and/or time)
_____________________________________________
Signature
_____________________________________________
Type or Print Name & Title
Date: ____________________________, 20_________
FCW (06/07)
(See attached page for instructions)
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