Foreign (non-Washington) Corporation - Certificate of Withdrawal

Office of the Sec retary of State
Corporations & Charities Division
APPLICATION FOR
CERTIFICATE OF WITHDRAWAL
RCW 23B.15.200
(Copies of RCW law may be obtained at local and state Libraries.)
0 1. Name of Corporation.
CHECKLIST
All documents must be typewritten or printed legibly in ink.
0 2. State or country of original incorporation.
0 3. Statement that corporation surrenders its authority to conduct affairs in Washington.
D 4. The corporation hereby revokes the authority of its registered agent in Washington to accept
service of process, and consents that service of process in any action, suit or proceeding based
upon any cause of action arising in Washington during the time the corporation was authorized
to conduct affairs in Washington may thereafter be made on the corporation by service thereof
on the Secretary of State of the state of Washington.
D 5. Attach a copy of revenue clearance certificate issued by the Department of Revenue.
D 6. Address to which copy of any process against the corporation that may be served on the
Secretary of State.
D 7. Commitment to notify the Secretary of State of any changes in the mailing address.
D 8. Document must be signed by Officer or Chairman of the Board.
D NO FILING FEE
The original and one (l) or more copies of this application must be delivered or mailed to:
CORPORATION DIVISION
James M. Dolliver Building
801 Capitol Way South
PO Box 40234
Olympia, WA 98504-0234
(360) 725-0377
010·003 B (2/96)

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Office of the Secretary of State
Corporations & Charities Division
UBI#: ______________________ __
Phone#: _____________ _
Pursuant to the provtstons of RCW 23B.15.200 the undersigned does hereby submit an
application for a Certificate of Withdrawal.
1. Name of the Corporation is:-------------------------
2. State or country of original incorporation:
3. Statement surrendering the corporations authority to conduct affairs in this state:
4. Corporation hereby revokes the authority of its registered agent in Washington to accept
service of process, and consents that service of process in any action, suit or proceeding
based upon any cause of action arising in Washington during the time the corporation was
authorized to conduct affairs in Washington may thereafter be made on the corporation by
service thereof on the Secretary of State of the state of Washington.
5. Attached is a copy of a revenue clearance certificate issued by the Department of Revenue.
6. Address in the "home" jurisdiction where service of process can be forwarded is:
7. The undersigned does hereby commit to notify the Secretary of State of any changes in the
mailing address
8. This document is hereby executed under penalties of perjury, and 1s, to the best of my
knowledge true and correct.
Dated: 20_
X _______________________________ __
(Signature of Officer or Chairman of the Board)
010-003 B (2/96)