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Form Scc767/929 - Application For A Certificate Of Withdrawal Of A Foreign Corporation Authorized To Transact Business In Virginia

SCC767/929

COMMONWEALTH OF VIRGINIA

(06/02)

STATE CORPORATION COMMISSION

APPLICATION FOR A CERTIFICATE OF WITHDRAWAL OF A

FOREIGN CORPORATION AUTHORIZED TO TRANSACT

BUSINESS IN VIRGINIA

The undersigned, pursuant to § 13.1-767 of the Virginia Stock Corporation Act, or §

13.1-929 of the Virginia Nonstock Corporation Act, executes this application and states as

follows:

The name of the corporation is:

__________________________________________________________________

The name of the state or country under whose law it is incorporated is:

__________________________________________________________________

The corporation is not transacting business in Virginia and surrenders its authority

to transact business in Virginia.

The corporation revokes the authority of its registered agent to accept service on its

behalf and appoints the Clerk of the Commission as its agent for service of process

in any proceeding based on a cause of action arising during the time it was

authorized to transact business in Virginia.

The mailing address to which the Clerk of the Commission may mail a copy of any

process served on him as agent for the corporation is:

__________________________________________________________________

The corporation commits to notify the Clerk of the Commission in the future of any

change in its mailing address.

The corporation certifies that it has filed returns and has paid all state taxes to the

time of this application (stock corporations only).

Executed in the name of the corporation:

_____________________________________

(signature)

_____________________________________

(printed name and corporate title)

The execution must be by the chairman or any vice-chairman of the board of

directors, the president, or any other of its officers authorized to act on behalf of the

corporation.

SEE INSTRUCTIONS ON THE REVERSE

Form Scc767/929 - Application For A Certificate Of Withdrawal Of A Foreign Corporation Authorized To Transact Business In Virginia