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Form L-15 - Application For Certificate Of Withdrawal By Reason Of Merger, Consolidation Or Conversion Page 2

Attached hereto is a copy of the articles of merger, consolidation or conversion or a certificate reciting the facts of

the merger, consolidation or conversion duly authenticated by the Secretary of State or other official having

custody of records of such entities in the state or country under the laws of which such merger was effected.

This application will be effective upon filing, unless a date and/or time is specified here:___________

This the ________day of ________________ , 20____

___________________________________

Name of Surviving/Resulting Entity

___________________________________

Signature

____________________________________

Type or Print Name and Title

NOTES

Filing fee is $10. This application and one exact or conformed copy of this application must be filed with the

Secretary of State. The application must be accompanied by a copy of the articles of merger, consolidation or

conversion or a certificate reciting the facts of the merger, consolidation or conversion duly authenticated by the

Secretary of State or other official having custody of the records of such entities in the state or country under the

laws of which the foreign entity was organized, incorporated or created.

This form is to be used only if the surviving corporation is not authorized to transact business or conduct affairs in

North Carolina.

(Revised January 2000)

(Form L-15)

CORPORATIONS DIVISION

P.O. BOX 29622

RALEIGH, NC 27626-0622

Form L-15 - Application For Certificate Of Withdrawal By Reason Of Merger, Consolidation Or Conversion Page 2