F0015 - Page 1 of 1 OFFICE OF THE MISSISSIPPI SECRETARY OF STATE P.O. BOX 136, JACKSON, MS 39205-0136 (601) 359-1333 Application for Certificate of Withdrawal *0015-1-1* The undersigned, pursuant to Section 79-4-15.20 (if a profit corporation) or Section 79-11-383 (if a nonprofit corporation) of the Mississippi Code of 1972, hereby executes the following document and sets forth: 1. Type of Corporation Profit Nonprofit 2. Name of the Corporation 3. The future effective date is (Complete if applicable) 4. Its state or country of incorporation is 5. The mailing address to which the Secretary of State may mail a copy of any process against the corporation that may be served on him/her City, State, ZIP5, ZIP4 - 6. The corporation is not transacting business in Mississippi and hereby surrenders its authority to transact business in Mississippi. 7. The corporation hereby revokes the authority of its registered agent in Mississippi to accept service on its behalf and appoints the Secretary of State as its agent for service of process in any proceeding based upon any cause of action arising during the time it was authorized to transact business in the State of Mississippi. 8. The corporation hereby makes a commitment to notify the Secretary of State in the future of any change in the mailing address given above. (Please keep writing within blocks) By: Signature Printed Name Title Rev. 01/96