Wyoming Secretary of State State Capitol Building, Room 110 200 West 24th Street Cheyenne, WY 82002-0020 Ph. 307.777.7311 Fax 307.777.5339 Email: business@state.wy.us For Office Use Only Foreign Profit Corporation Application for Certificate of Withdrawal Pursuant to W.S. 17-16-1520 of the Wyoming Business Corporation Act, the undersigned corporation hereby applies for a Certificate of Withdrawal from the state of Wyoming, and for that purpose submits the following statement: 1. Corporation name: 2. Incorporated under the laws of: (State or country of incorporation) 3. It is no longer transacting business in the state of Wyoming; and it hereby surrenders its authority to transact business in the state of Wyoming. 4. It revokes the authority of its registered agent to accept service on its behalf and appoints the Wyoming 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. 5. Mailing address to which the Secretary of State may mail a copy of any process served on him under Item 4: 6. It will notify the Wyoming Secretary of State in the future of any change in its mailing address. Date: Signature: ___________________________________________ (mm/dd/yyyy) (May be executed by Chairman of Board, President or another of its officers.) Print Name: Title: Contact Person: Daytime Phone Number: Checklist Filing Fee: $50.00 Make check or money order payable to Wyoming Secretary of State. Please submit one originally signed document and one exact photocopy of the filing. Please review form prior to submitting to the Secretary of State to ensure all areas have been completed to avoid a delay in the processing of your documents. FP-CertificateWithdrawal - Revised 12/2008 American LegalNet, Inc. www.FormsWorkFlow.com