Application Form For Certificate Of Withdrawal Of Foreign Nonprofit Corporation
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1APPLICATION FOR CERTIFICATE OF WITHDRAWAL
OF FOREIGN NONPROFIT CORPORATION
Wyoming Secretary of State
Phone (307) 777-7311/7312
The Capitol Building, Room 110
Fax (307) 777-5339
200 W. 24th Street
E-mail: corporations@state.wy.us
Cheyenne, WY 82002-0020
Pursuant to W.S. 17-19-1520 of the Wyoming Nonprofit Corporation Act, the undersigned corporation
hereby applies for a Certificate of Withdrawal from the state of Wyoming, and for that purpose submits the follow-
ing statement:
FIRST:
The name of the corporation is: _________________________________________________
________________________________________________________________________
SECOND:
It is incorporated under the laws of ______________________________________________.
THIRD:
It is no longer transacting business in this state; and it hereby surrenders its authority to
transact business in the state of Wyoming.
FOURTH:
It revokes the authority of its registered agent to accept service on its behalf and appoints the
Secretary of State 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 this state.
FIFTH:
A mailing address to which the Secretary of State may mail a copy of any process
served on him under Item Four:
________________________________________________________________________
________________________________________________________________________
SIXTH:
It will notify the Secretary of State in the future of any change in its mailing address.
Date:_________________________
Signed: ____________________________________
Title:______________________________________
************************************************************************************
Filing Fee: $10.00
Instructions:
1.
The document shall be executed by the Chairman of Board of Directors or by its President
or by another of its officers.
2.
The document shall be accompanied by one (1) exact or photo copy.
npcwth - Revised: 9/2003
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