Form F0015 - Application For Certificat Eof Withdrawal - Mississippi Secretary Of State

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F0015 - Page 1 of 1
OFFICE OF THE MISSISSIPPI SECRETARY OF STATE
P.O. BOX 136, JACKSON, MS 39205-0136
(601) 359-1333
*0015-1-1*
Application for Certificate of Withdrawal
The undersigned, pursuant to Section 79-4-15.20 (if a profit corporation) or Section 79-11-383 (if
a nonprofit corporation) of the Mississippi Code of 1972, hereby executes the following document
and sets forth
:
1. Type of Corporation
Profit
Nonprofit
2. Name of the Corporation
3. The future effective date is
(Complete if applicable)
4. Its state or country of incorporation is
5. The mailing address to which the Secretary of State may mail a copy of any process
against the corporation that may be served on him/her
-
City, State, ZIP5, ZIP4
6. The corporation is not transacting business in Mississippi and hereby surrenders its
authority to transact business in Mississippi.
7. The corporation hereby revokes the authority of its registered agent in Mississippi to
accept service on its behalf and 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 the State of Mississippi.
8. The corporation hereby makes a commitment to notify the Secretary of State in the future
of any change in the mailing address given above.
(Please keep writing within blocks)
By:
Signature
Printed Name
Title
Rev. 01/96

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