Form 154 - Application For Certificate Of Withdrawal - Rhode Island Department Of State Page 2

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State of Rhode Island and Providence Plantations
Department of State - Business Services Division
Filer Contact Information
In the event our office needs more information in order to complete the filing of this
document, we ask for the filer’s contact information. All fields are REQUIRED.
Name:
Date:
Entity Name:
Street Address:
City:
State:
Zip Code:
Email Address:
Phone Number:
If you have any questions, please call us at (401) 222-3040, Monday through Friday,
between 8:30 a.m. and 4:30 p.m., or email corporations@sos.ri.gov.
FORM 154 - Revised: 06/2016

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