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

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
(Check all applicable)

Director
Officer (give
title below)

(Street)

(City)
1. Title of Security
(Instr. 4)

(State)

(Zip)

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10% Owner
Other (specify
below)

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

6. Individual or Joint/Group
Filing (Check Applicable Line)

__Form filed by One Reporting Person
__Form filed by More than One ReportingPerson

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

3. Ownership
4. Nature of Indirect Beneficial Ownership
Form: Direct
(Instr. 5)
(D) or Indirect
(I) (Instr. 5)

Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
* If the form is filed by more than one reporting person, see Instruction 5(b)(v).
Potential persons who are to respond to the collection of information contained in this form are not
required to respond unless the form displays a currently valid OMB control number.

(Over)
SEC 1473 (11-11)

FORM 3 (continued)
1. Title of Derivative Security
(Instr. 4)

Table II — Derivative Securities Beneficially Owned ( e.g., puts, calls, warrants, options, convertible securities)
2. Date Exercisable and
Expiration
Date

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

(Month/Day/Year)

Date
Exercisable

Expiration
Date

Title

Amount
or
Number
of
Shares

4. Conver- 5. Owner- 6. Nature of Indirect
ship
sion or
Beneficial Ownership
Form of
Exercise
(Instr. 5)
DerivPrice of
ative
DeriSecurity:
vative
Direct
Security
(D) or
Indirect
(I)
(Instr. 5)

Explanation of Responses:

** 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

Date

Note: File three copies of this Form, one of which must be manually signed. If space is insufficient,
See Instruction 6 for procedure.
Potential persons who are to respond to the collection of information contained in this form are not
required to respond unless the form displays a currently valid OMB Number.
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