Looking for a North Carolina Secretary Of State Forms And Templates? Download it for free!

State of North Carolina

Department of the Secretary of State

APPLICATION FOR CERTIFICATE OF WITHDRAWAL

BY REASON OF MERGER, CONSOLIDATION

OR CONVERSION

Pursuant to §55-15-21, §55A-15-21, § 57C-7-12, or § 59-909, as applicable, of the General Statutes of North Carolina,

the undersigned entity, as the surviving or resulting entity in a statutory merger, consolidation or conversion hereby

applies to the Secretary of State for a Certificate of Withdrawal for the foreign entity(ies) authorized to transact

business or conduct affairs in the State of North Carolina named below, whose separate existence has ceased as a result

of the merger, consolidation or conversion, and for that purpose submits the following statement:

1. The name of the surviving or resulting entity is:___________________________________________

The surviving or resulting entity is incorporated, organized or created under the laws of:

______________________________________________________________________________

The type of entity of the surviving or resulting entity:___________________________________

______________________________________________________________________________

The surviving or resulting entity is not authorized to transact business or conduct affairs in the State of North

Carolina.

The name of each foreign entity authorized to transact business in North Carolina (and its fictitious name used in

the State of North Carolina, if different from its official name) is:__________________

__________________________________________________________________________________

The name of the state or country under whose law each such entity was incorporated, organized or created

is:______________________________________________________________________

______________________________________________________________________________

The type of entity of each foreign entity:______________________________________________

______________________________________________________________________________

The surviving or resulting entity hereby consents that service of process based on any cause of action arising in the

State of North Carolina, or arising out of business transacted or affairs conducted in this State during the time each

foreign entity was authorized to transact business or conduct affairs in this State may thereafter be made by

service thereof on the Secretary of State.

The mailing address to which the Secretary of State may mail a copy of any process served pursuant to the

paragraph above is:

C/O______________________________________________________________________________

Address___________________________________________________________________________

City, State, Zip Code_________________________________________________________________

The surviving or resulting entity hereby agrees to notify the Secretary of State in the future of any change in its

mailing address.

Form L-15 - Application For Certificate Of Withdrawal By Reason Of Merger, Consolidation Or Conversion