Department of Commerce, Community, and Economic Development Corporations, Business and Professional Licensing CORPORATIONS SECTION PO Box 110808 Juneau AK 99811-0808 APPLICATION FOR CERTIFICATE OF WITHDRAWAL For Foreign Business, Non Profit, or Cooperative Corporation Pursuant to the provisions of the Alaska Statutes, the undersigned corporation applies for a certificate of withdrawal. 1. Name of the corporation: Alaska Entity #: 2. State or country of domicile: 3. 4. 5. 6. The corporation is not transacting business in Alaska. The corporation surrenders its authority to transact business in Alaska. The corporation hereby revokes its authority to transact business in Alaska. The corporation hereby revokes the authority of its registered agent in Alaska and consents that service of process may subsequently be made on the company by service on the Commissioner of the department. 7. The mailing address where the Commissioner may mail any process against the corporation that may be served on the corporation: Name: Mailing Address: Physical Address if Mailing Address is a Post Office Box: City: State: ZIP Code: The Application of Withdrawal must be signed by the corporation’s president or vice president and by the secretary or assistant secretary. Signed this , 20 day of Signature of President or Vice President . Printed Name Signature of Secretary or Assistant Secretary Printed Name If you have specific legal questions or concerns about this filing, you are strongly advised to consult an attorney or other professional to assist you. Mail the completed filing and $25.00 filing fee (in U.S. dollars) to: State of Alaska Corporations Section PO Box 110808 Juneau, AK 99811 For additional information or forms please visit our web site at: www.corporations.alaska.gov 08-470 (Rev. 8/05) alh -1- American LegalNet, Inc. www.USCourtForms.com