State of North Carolina
Department of the Secretary of State
APPLICATION FOR CERTIFICATE OF WITHDRAWAL
BY REASON OF MERGER, CONSOLIDATION
OR CONVERSION
Pursuant to §55-15-21, §55A-15-21, § 57D-7-21, § 59-91 or § 59-909, of the General Statutes of North Carolina
as applicable, the undersigned entity, as the surviving or resulting entity in a statutory merger, consolidation or
conversion hereby applies to the Secretary of State for a Certificate of Withdrawal for the foreign entity(ies)
authorized to transact business or conduct affairs in the State of North Carolina named below, whose separate
existence has ceased as a result of the merger, consolidation or conversion, and for that purpose submits the
following statement:
1. The name of the surviving or resulting entity is:
______________________________________________________________________________________
a. The surviving or resulting entity is incorporated, formed or created under the laws of:
____________________________________________________________________________________
b. The type of entity of the surviving or resulting entity:_________________________________________
2. The surviving or resulting entity is not authorized to transact business or conduct affairs in the State of
North Carolina.
3. The name of the merging or converted foreign entity authorized to transact business in North Carolina, its
fictitious name used in the State of North Carolina, if different from it official name, the state or country
under whose law the entity was incorporated, formed or created, and the type of entity of the foreign entity.
Official Name
Fictitious Name,
if any
State or Country
Type of Entity
4. The surviving or resulting entity hereby consents that service of process based on any cause of action arising
in the State of North Carolina, or arising out of business transacted or affairs conducted in this State during
the time each foreign entity was authorized to transact business or conduct affairs in this State may
thereafter be made by service thereof on the Secretary of State.
CORPORATIONS DIVISION
P.O. BOX 29622
RALEIGH, NC 27626-0622
(Revised January 2014)
(Form BE-09)
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