You may not send a completed printout of this form to the SEC to satisfy a filing
obligation. You can only satisfy an SEC filing obligation by submitting the ...
You may not send a completed printout of this form to the SEC to satisfy a filing obligation. You can only satisfy an SEC filing obligation by submitting the information required by this form to the SEC in electronic format online at https://www.onlineforms.edgarfiling.sec.gov.
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)
OMB APPROVAL OMB Number: 3235-0104 Expires: March 31, 2018 Estimated average burden hours per response. . . . . . 0.5
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. Page 2
