APPLICATION FOR WITHDRAWAL
OF
________________________________________________
A _____________________________ Corporation
[state, province or country]
1. The name of the foreign corporation is _________________________________________.
It is incorporated under the laws of _____________________________________.
[state, province or country]
2. The foreign corporation is not transacting business/conducting affairs in this state and does hereby
surrender its authority to do so in this state.
3. The foreign corporation does hereby revoke the authority of its statutory agent to accept process on
its behalf and does hereby appoint the Arizona Corporation Commission 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/conduct affairs in this state.
4. Upon receipt of any process served upon it on behalf of the foreign corporation, the Arizona
Corporation Commission is requested to mail a copy to:
________________________________
________________________________
________________________________
5. The foreign corporation will notify the Arizona Corporation Commission in the future of any change
in the mailing address of the foreign corporation.
This application will not be complete until the Arizona Corporation Commission has
received from the department of revenue a notice that all transaction privilege taxes have
been paid or are not due and a certificate from the department of revenue that all income tax
returns have been filed and taxes paid.
DATED this ____ day of ____________________, _____.
______________________________________
[Name of Corporation]
By______________________________________
______________________________________
CF: 0025
[name]
[title]
Rev: 5/00