Form Mnpca-12b - Application For Surrender Of Authority To Carry On Activities - 2010 Page 2

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DATED _________________________
*By___________________________________________
(signature of any duly authorized individual)
___________________________________________
(type or print name and capacity)
*This document MUST be signed by any duly authorized individual.
SUBMIT COMPLETED FORMS TO: CORPORATE EXAMINING SECTION, SECRETARY OF STATE,
101 STATE HOUSE STATION, AUGUSTA, ME 04333-0101
FORM NO. MNPCA-12B Rev. 3/16/2010
TEL. (207) 624-7740

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