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Form Mnpca-12b - Application For Surrender Of Authority To Carry On Activities - 2010

Filing Fee $15.00

FOREIGN

NONPROFIT CORPORATION

STATE OF MAINE

APPLICATION FOR

_____________________

SURRENDER OF AUTHORITY

Deputy Secretary of State

TO CARRY ON ACTIVITIES

A True Copy When Attested By Signature

_____________________

______________________________________

Deputy Secretary of State

(Name of Corporation)

Pursuant to 13-B MRSA §1208, the undersigned foreign corporation hereby executes and delivers for filing this Application for Surrender

of Authority to Carry on Activities in the State of Maine:

FIRST:

The jurisdiction of its incorporation is _______________________________________________________________

SECOND:

The date on which it was authorized to carry on activities in the State of Maine is ___________________________

THIRD:

The corporation is not as of the date of this application carrying on activities in the State of Maine and surrenders its

authority to carry on activities in the state.

FOURTH:

The corporation revokes the authority of its registered agent in the State of Maine to accept service of process; it

consents that process in any action, suit or proceeding based upon any cause of action arising in the State of Maine

prior to the date of filing this application may be served on the Secretary of State after the date of the filing of this

application.

FIFTH:

The post-office address to which the Secretary of State shall mail a copy of any process served upon him against the

corporation is ___________________________________________________________________________________

(street, city, state and zip code)

SIXTH:

The address of the principal or registered office of the corporation, wherever located, is

_______________________________________________________________________________________________

(street, city, state and zip code)

Form Mnpca-12b - Application For Surrender Of Authority To Carry On Activities - 2010