FORM 3 (Print or Type Responses) |
UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934, Section 17(a) of the Public Utility Holding Company Act of 1935 or Section 30(f) of the Investment Company Act of 1940 |
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1. | Name and Address of Reporting Person* | 2. | Date of Event Requiring Statement (Month/Day/Year) |
4. | Issuer Name and Ticker or Trading Symbol | |||||||||||||||
Henriksen, Ronald | August 1, 2002 | MacroPore Biosurgery, Inc. | ||||||||||||||||||
(Last) | (First) | (Middle) | 3. | I.R.S. Identification Number of Reporting Person, if an entity (voluntary) | 5. | Relationship of Reporting Person(s) to Issuer (Check all applicable) | 6. | If Amendment, Date of Original (Month/Day/Year) |
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6642 E. CR 200 N. | X Director | 10% Owner | ||||||||||||||||||
(Street) |
Officer (give title below) |
Other (specify below) |
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Avon, IN 46123 | 7. | Individual or Joint/Group Filing | ||||||||||||||||||
(Check Applicable Line) | ||||||||||||||||||||
(City) | (State) | (Zip) | X Form filed by One Reporting Person Form filed by More than One Reporting Person |
Table I Non-Derivative Securities Beneficially Owned
1. | Title of Security (Instr. 4) |
2. | Amount of Securities Beneficially Owned (Instr. 4) |
3. | Ownership Form: Direct (D) or Indirect (I) (Instr. 5) |
4. | Nature of Indirect Beneficial Ownership (Instr. 5) |
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* If the form is filed by more than one reporting person, see Instruction 5(b)(v).
Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
(Print or Type Responses)
FORM 3 (Continued) | Table II Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) |
1. | Title of Derivative Security (Instr. 4) |
2. | Date Exercisable and Expiration Date | 3. | Title and Amount of Securities Underlying Derivative Security (Instr. 4) |
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) |
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Date Exercisable |
Expiration Date |
Title | Amount or Number of Shares | |||||||||||||||||||||||
Explanation of Responses:
By: | /s/ RONALD HENRIKSEN **Signature of Reporting Person |
October 30, 2002 Date |
** |
Intentional misstatements or omissions of facts constitute Federal Criminal Violations. See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). |
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Note: |
File three copies of this Form, one of which must be manually signed. If space is insufficient, see Instruction 6 for procedure. |
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