For Office Use Only APPLICATION FOR CERTIFICATE OF WITHDRAWAL Corporate Filings 312 Rosa L. Parks Avenue 6th Floor, William R. Snodgrass Tower Nashville, TN 37243 To the Secretary of State of the State of Tennessee: Pursuant to the provisions of Section 48-25-201 of the Tennessee Business Corporation Act or Section 48-65-201 of the Tennessee Nonprofit Corporation Act, the undersigned corporation hereby applies for a certificate of withdrawal from the State of Tennessee, and for that purpose sets forth: 1. The name of the corporation is . If different, the name under which the certificate of authority was obtained is . 2. The state or country under whose law it is incorporated is . 3. The corporation is not transacting business in the State of Tennessee and surrenders its authority to transact business in this state. 4. Please mark/complete the applicable statement: The corporation continues its registered agent and registered office in the State of Tennessee. The corporation hereby 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. The mailing address (including zip code) to which the Secretary of State may mail a copy of any process served on him is: . 5. The undersigned corporation makes the commitment to notify the Secretary of State in the future of any change in its mailing address. [NOTE: Prior to this document being accepted for filing, the Division of Business Services will request tax clearance verification from the Tennessee Department of Revenue that the business has properly filed all reports and paid all required taxes and penalties. If we cannot obtain such tax clearance verification from the Department of Revenue, this document will be rejected and returned to the applicant.] Signature Date Name of Corporation Signer’s Capacity Signature Name (typed or printed) SS-4437 (Rev. 8/08) Filing Fee $20.00 RDA 1678 American LegalNet, Inc. www.FormsWorkflow.com