Statement Of Cancellation Form 2009
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1ROSS MILLER
Secretary of State
204 North Carson Street, Suite 1
Carson City, Nevada 89701-4520
(775) 684 5708
Website:
Statement of Cancellation
by Nonfiling Domestic and Nonqualified Foreign Entities
(PURSUANT TO NRS 77.380)
USE BLACK INK ONLY - DO NOT HIGHLIGHT
ABOVE SPACE IS FOR OFFICE USE ONLY
1. Name of Entity:
2. File Number:
3. This entity is canceling its appointment of the following registered agent as agent for
service of process in Nevada:
4. Signature:
X
Date
Authorized Signature of Nonfiling Entity
FEE: $50.00
This form must be accompanied by appropriate fees.
Nevada Secretary of State Form RA Misc Cancellation
Reset
Effective: 5-15-09
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