Filing Fee $15.00 FOREIGN NONPROFIT CORPORATION STATE OF MAINE APPLICATION FOR SURRENDER OF AUTHORITY TO CARRY ON ACTIVITIES _____________________ Deputy Secretary of State A True Copy When Attested By Signature ______________________________________ (Name of Corporation) _____________________ Deputy Secretary of State Pursuant to 13-B MRSA §1208, the undersigned foreign corporation hereby executes and delivers for filing this Application for Surrender of Authority to Carry on Activities in the State of Maine: FIRST: SECOND: THIRD: The jurisdiction of its incorporation is _______________________________________________________________ The date on which it was authorized to carry on activities in the State of Maine is ___________________________ The corporation is not as of the date of this application carrying on activities in the State of Maine and surrenders its authority to carry on activities in the state. FOURTH: The corporation revokes the authority of its registered agent in the State of Maine to accept service of process; it consents that process in any action, suit or proceeding based upon any cause of action arising in the State of Maine prior to the date of filing this application may be served on the Secretary of State after the date of the filing of this application. FIFTH: The post-office address to which the Secretary of State shall mail a copy of any process served upon him against the corporation is ___________________________________________________________________________________ (street, city, state and zip code) SIXTH: The address of the principal or registered office of the corporation, wherever located, is _______________________________________________________________________________________________ (street, city, state and zip code) American LegalNet, Inc. www.FormsWorkFlow.com 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) 624-7752 American LegalNet, Inc. www.FormsWorkFlow.com Filer Contact Cover Letter To: Department of the Secretary of State Division of Corporations, UCC and Commissions 101 State House Station Augusta, ME 04333-0101 Tel. (207) 624-7752 Name of Entity (s): _______________________________________________________________________ _______________________________________________________________________ List type of filing(s) enclosed (i.e. Articles of Incorporation, Articles of Merger, Articles of Amendment, Certificate of Correction, etc.) Attach additional pages as needed. ________________________________________________________________________ ________________________________________________________________________ Special handling request(s): (check all that apply) Hold for pick up Expedited filing - 24 hour service ($50 additional filing fee per entity, per service) Expedited filing - Immediate service ($100 additional filing fee per entity, per service) Total filing fee(s) enclosed: $ ________________ Contact Information ­ questions regarding the above filing(s), please call or email: (failure to provide a contact name and telephone number or email address will result in the return of the erroneous filing (s) by the Secretary of State's office) ___________________________________ (Name of contact person) ___________________________________ (Daytime telephone number) ____________________________________________________ (Email address) The enclosed filing(s) and fee(s) are submitted for filing. Please return the attested copy to the following address: ______________________________________________________________________________ (Name of attested recipient) _____________________________________________________________________________________________ (Firm or Company) _____________________________________________________________________________________________ (Mailing Address) _____________________________________________________________________________________________ (City, State & Zip) American LegalNet, Inc. www.FormsWorkFlow.com