Wyoming Secretary of State 
                              Herschler Building East, Suite 101
                                                                                   For Office Use Only 
                                  122 W 25th Street
                               Cheyenne, WY 82002-0020 
                                  Ph. 307.777.7311 
                                  Email: Business@wyo.gov   

                                  Foreign Nonprofit Corporation 
                              Application for Certificate of Withdrawal 

Pursuant to W.S. 17-19-1520 the undersigned corporation hereby applies for a Certificate of Withdrawal from the 
state of Wyoming. 

1. Corporation name:

2. Incorporated under the laws of:
                                  (State or country) 

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 Secretary of State in the future of any change in its mailing address.

Signature: ___________________________________________                        Date: 
(May be executed by Chairman of Board, President or another of its officers.)                (mm/dd/yyyy) 

Print Name:                                         Contact Person: 

Title:                                              Daytime Phone Number: 

                                                    Email:  

                                                   (An email address is required. Email(s) provided will receive 
                                                   important reminders, notices and filing evidence.)
Checklist 
       Filing Fee: $25.00 Make check or money order payable to Wyoming Secretary of State. 
       Processing time is up to 15 business days following the date of receipt in our office.
       The business entity is active and in good standing with this office. 
       Please mail with payment to the address at the top of this form. This form cannot be accepted via email.
       Please review the form prior to submission. The Secretary of State’s Office is unable to process incomplete forms.

FNP-CertificateWithdrawal - Revised June 2021