ROSS MILLER Secretary of State 202 North Carson Street Carson City, Nevada 89701-4201 (775) 684-5708 Website: www.nvsos.gov *021301* Nevada State Business License *021301* Cancellation Statement "Other" USE BLACK INK ONLY - DO NOT HIGHLIGHT ABOVE SPACE IS FOR OFFICE USE ONLY Completing this form does not relieve you of any statutory or regulatory requirements relating to your business. This form is for the use of a business that is not a sole proprietor or partnership or that is not required to organize pursuant to Title 7 of the NRS. It MAY NOT be used by those entities organized pursuant to NRS Title 7 and on file with the Secretary of State that file an annual list. * Asterisks indicate required information. Incomplete forms will be rejected. 1* Name as it appears on Business License 2* NV Business ID # (NV Secretary of State - issued, may be found on business license certificate) 3 Pursuant to Chapter 76 of Nevada Revised Statutes, this serves as notification that the above named business will no longer be conducting business in the State of Nevada and desires to cancel its State Business License as of: (effective date) 4* Signature must be that of a responsible party of the entity canceling its State Business License. I declare under penalty of perjury that the information provided is true, correct and complete to the best of my knowledge and belief and acknowledge that pursuant to NRS 239.330, it is a category C felony to knowingly offer any false or forged instrument for filing in the Office of the Secretary of State. First Name Middle (Optional) Last Name Suffix Title X Signature Date Nevada Secretary of State Busn License Cancel Other Revised: 8-4-10 American LegalNet, Inc. www.FormsWorkFlow.com