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:  

                                                   (Email provided will receive filing evidence)  *May list multiple email addresses

Checklist 
       Filing Fee: $10.00   Make check or money order payable to Wyoming Secretary of State.           
                                                       
       Please submit one originally signed document. 
       The business entity is active and in good standing with this office. 
       Typical processing time is 3-5 business days following the date of receipt in our office.            
       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. 
FNP-CertificateWithdrawal - RevisedAugust 2019