APPLICATION FOR WITHDRAWAL (foreign profit or non-profit corporation or foreign LLC) Vermont Secretary of State, 81 River Street, Montpelier, VT 05609-1104 Telephone: 802-828-2386; Fax: 802-828-2853; CORPORATE/LLC NAME: Incorporated or organized under the laws of the state (country) of is no longer transacting business in Vermont and surrenders its authority to transact business. Above corporation/llc 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 or was transacting without authorization, in this State. The mailing address where service of process may be sent is: The above company will notify the Secretary of State of any change in its mailing address. All corporate taxes and fees due the State of Vermont have been paid. Printed Name Signature __________________________________Date___________ Title Fee: $ 20.00 (mandatory) (e.g. Executive Director, Secretary) Please type or print and file in duplicate so we can return a copy for your records! Revised 3/1/04 American LegalNet, Inc. www.FormsWorkflow.com