SEC 1473 Form 3 - Initial Statement of Beneficial Ownership of Se

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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549

FORM 3

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Form 3

INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES
(Print or Type Responses)
1. Name and Address of Reporting Person*

(Last)

(First)

2. Date of Event Requiring
Statement
(Month/Day/Year)

(Middle)

3. Issuer Name and Ticker or Trading Symbol

4. Relationship of Reporting Person(s) to
Issuer
(Click all applicable)
Director
10% Owner

(Street)

(City)

Officer (give
title below)

(State)

1. Title of Security
(Instr. 4)

(Zip)

Other (specify
below)

5. If Amendment, Date of Original
Filed (Month/Day/Year)

6. Individual or Joint/Group
(Check Applicable Line)
Form filed by One Reporting
Person
Form filed by More than One
Reporting Person

Table I — Non-Derivative Securities Beneficially Owned
2. Amount of Securities
Beneficially Owned
(Instr. 4)

3. Ownership From:
Direct (D) or
Indirect (I) (Instr. 5)

3. Nature of Indirect Beneficial Ownership
(Instr. 5)

* If the form is filed by more than one reporting person, see Instruction 4(b)(v).
SEC 1473 (11-11)

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FORM 3 (continued) Table I — Non- Derivative Securities Beneficially Owned
1. Title of Security
(Instr. 4)

2. Amount of Securities
Beneficially Owned
(Instr. 4)

3. Ownership From:
Direct (D) or
Indirect (I) (Instr. 5)

3. Nature of Indirect Beneficial Ownership
(Instr. 5)

Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.

Page 2 of 4

FORM 3 (continued) Table II — Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities)
1. Title of Security
(Instr. 4)

2. Date Exercisable
and Expiration
Date (Month/Day/
Year)

Date
Exercisable

Expiration Date

3. Title and Amount of Securities
Underlying Derivative Security
(Instr. 4)

Title

Explanation of Responses:

Page 3 of 4

Amount
or
Number
of
Shares

4.
Conversion or
Exercise
Price of
Derivative
Security

5.
Ownership
Form of
Derivative
Security
Direct (D)
or Indirect
(I)
(Instr. 5)

6. Nature of Indirect
Beneficial Ownership
(Instr. 5)

** Intentional misstatements or omissions of
facts constitute Federal Criminal Violations.
See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a).

**Signature of Reporting Person

Note: File three copies of this Form, one of which must be manually signed.
If space is insufficient, see Instruction 6 for procedure.

Page 4 of 4

Date