WWW.BUSINESSREGISTRATIONS.COM                                 FORM FC-4 
Nonrefundable Filing Fee: 
Profit: $25.00                                                           7/2011
Nonprofit: $10.00

No personal or business checks accepted.  
Payment of the filing fee should be ONLY in the form of CASH, CERTIFIED/CASHIER'S CHECK, 
BANK/POSTAL MONEY ORDER OR CREDIT CARD (VISA OR MasterCard).  
Make check or money order payable to DEPARTMENT OF COMMERCE AND CONSUMER 
AFFAIRS.  Dishonored Check Fee $25.00. 
 

WWW.BUSINESSREGISTRATIONS.COM                               STATE OF HAWAII                                                           FORM FC-4 
Nonrefundable Filing Fee:                       DEPARTMENT OF COMMERCE AND CONSUMER AFFAIRS
Profit: $25.00                                                                                                                        7/2011
                                                    Business Registration Division 
Nonprofit: $10.00No personal or business checks             335 Merchant Street 
                                                Mailing Address: P.O. Box 40, Honolulu, Hawaii 96810                               *FC4* 
accepted. 
          See instructions.                                 Phone No. (808)586-2727 
                                                                  
   Clear Form

                          APPLICATION FOR WITHDRAWAL, FOREIGN CORPORATION 
                                                (Section 414-451, 414D-282, Hawaii Revised Statutes) 
                                                                 
PLEASE TYPE OR PRINT LEGIBLY IN BLACK INK 
  
The undersigned, duly authorized officers of the corporation submitting this application, certify as follows:

1.             The corporation is (check one):       Profit                      Nonprofit
                                                    (F/$25/B24)                 (F/$10/B24)

2.             The name of the corporation is:

3.             The corporation was incorporated in:

4.             The corporation is not transacting business, and surrenders its authority to transact business in the State of Hawaii.

5.             The corporation revokes the authority of its registered agent in the State of Hawaii to accept service of process and consents 
               that service of process in any action or proceeding based upon any cause of action arising in this State during the time the 
               corporation was authorized to transact business in this State may hereafter be made on such corporation by service thereof  
               on the Director of Commerce and Consumer Affairs.

6.             The complete mailing address to which the director may mail a copy of any process against the corporation that may be  
               served on the director is:         

We certify under the penalties of Section 414-20, 414D-12, Hawaii Revised Statutes, as applicable, that we have read the above 
statements, we are authorized to sign the application, and that the above statements are true and correct.

Signed this                 day of                                ,

                          (Type/Print Name & Title)                                                          (Type/Print Name & Title)

                          (Signature of Officer)                                                             (Signature of Officer)

SEE INSTRUCTIONS ON REVERSE SIDE. Application must be signed by at least one officer of the corporation or by the chairperson of the board of 
directors. 
 

                                                                                                                  FORM FC-4 
                                                                                                                                              7/2011

Instructions:  Application must be typewritten or printed in black ink, and must be legible. Application must be signed by at least one 
officer of the corporation or by the chairperson of the board of directors. All signatures must be in black ink.  Submit original application 
together with the appropriate fee(s).   
 
Line 1.    Check whether the corporation is a profit or a nonprofit corporation. 
 
Line 2.  State the full name of the corporation. 
 
Line 3.  Give the name of the state or country where it was incorporated. 
 
Line 6.  Give the complete mailing address (including city, state and zip code) where any process may be mailed to the corporation by 
  the Director of Commerce and Consumer Affairs. 
 
Filing Fees:  Filing fees are not refundable. No personal or business checks accepted. Payment of the filing fee should be ONLY 
in the form of CASH, CERTIFIED/CASHIER'S CHECK, BANK/POSTAL MONEY ORDER OR CREDIT CARD (Visa or MasterCard). 
Make check or money order payable to DEPARTMENT OF COMMERCE AND CONSUMER AFFAIRS.   
 
  Foreign Profit ($25) 
  Foreign Nonprofit ($10) 
    
  Dishonored Check Fee ($25) 
   
For any questions call (808)586-2727. Neighbor islands may call the following numbers followed by 6-2727 and the # sign: Kauai 
274-3141; Maui 984-2400; Hawaii 974-4000, Lanai and Molokai 1-800-468-4644 (toll free). 
  
Fax (808)586-2733 Email Address: breg@dcca.hawaii.gov 
  
ALL BUSINESS REGISTRATION FILINGS ARE OPEN TO PUBLIC INSPECTION. (SECTION 92F-11, HRS) 
 
NOTICE:  THIS MATERIAL CAN BE MADE AVAILABLE FOR INDIVIDUALS WITH SPECIAL NEEDS.  PLEASE CALL THE 
DIVISION SECRETARY, BUSINESS REGISTRATION DIVISION, DCCA, AT 586-2744, TO SUBMIT YOUR REQUEST.