SEC FORM
3
SEC Form 3
| FORM 3 |
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
or Section 30(h) of the Investment Company Act of 1940
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| OMB APPROVAL |
| OMB Number: |
3235-0104 |
| Estimated average burden |
| hours per response: |
0.5 |
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1. Name and Address of Reporting Person*
| C/O LEMAITRE VASCULAR, INC. |
| 63 SECOND AVENUE |
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year)
08/20/2015
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3. Issuer Name and Ticker or Trading Symbol
LEMAITRE VASCULAR INC
[ LMAT ]
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
|
Director |
|
10% Owner |
| X |
Officer (give title below) |
|
Other (specify below) |
| VP of Sales, The Americas |
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5. If Amendment, Date of Original Filed
(Month/Day/Year)
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6. Individual or Joint/Group Filing (Check Applicable Line)
| X |
Form filed by One Reporting Person |
|
Form filed by More than One Reporting Person |
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| Table I - Non-Derivative Securities Beneficially Owned |
|---|
| 1. Title of Security (Instr.
4)
|
2.
Amount of Securities Beneficially Owned (Instr.
4)
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3. Ownership Form: Direct (D) or Indirect (I) (Instr.
5)
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4. Nature of Indirect Beneficial Ownership (Instr.
5)
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Table II - Derivative Securities Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
|
|---|
| 1. Title of Derivative Security (Instr.
4)
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2. Date Exercisable and Expiration Date
(Month/Day/Year) |
3. Title and Amount of Securities Underlying Derivative Security (Instr.
4)
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4. Conversion or Exercise Price of Derivative Security
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5. Ownership Form: Direct (D) or Indirect (I) (Instr.
5)
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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: |
| Remarks: |
|
| No securities are beneficially owned. |
|
/s/ Laurie A. Churchill, Attorney-in-fact |
08/28/2015 |
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** Signature of Reporting Person |
Date |
| 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). |
| ** Intentional misstatements or omissions of facts constitute Federal Criminal Violations
See
18 U.S.C. 1001 and 15 U.S.C. 78ff(a). |
| Note: File three copies of this Form, one of which must be manually signed. If space is insufficient,
see
Instruction 6 for procedure. |
| Persons who respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB Number. |
POWER OF ATTORNEY
KNOW ALL MEN BY THESE PRESENTS, that the person whose signature appears
below hereby constitutes and appoints
each of Laurie A. Churchill, Nicole C. Brookshire and Pamela L. Finan, signing
singly and each acting individually,
as the undersigned's true and lawful attorney-in-fact and agent, with full power
of substitution and resubstitution,
for the undersigned and in the undersigned's name, place, and stead, in any and
all capacities to sign any and all
instruments, certificates, and documents approved by the undersigned that, as a
result of the undersigned's service
as an executive officer or director of LeMaitre Vascular, Inc. (the "Company"),
are required to be executed on
behalf of the undersigned pursuant to Sections 13 and 16 of the Securities
Exchange Act of 1934, as amended
(the "Exchange Act"), and any and all regulations promulgated thereunder, and to
file the same, with all exhibits
thereto, and any other documents in connection therewith, with the Securities
and Exchange Commission, and with any
other entity when and if such is mandated by the Exchange Act, granting unto
said attorney-in-fact and agent full
power and authority to do and perform each and every act and thing requisite and
necessary fully to all intents and
purposes as the undersigned might or could do in person thereby ratifying and
confirming all that said
attorney-in-fact and agent, or her substitute or substitutes, may lawfully do or
cause to be done by virtue hereof.
The undersigned acknowledges that this Power of Attorney authorizes, but
does not require, each such
attorney-in-fact to act in their discretion on information provided to such
attorney-in-fact without independent
verification of such information; any documents prepared and/or executed by any
such attorney-in-fact on behalf of
the undersigned pursuant to this Power of Attorney will be in such form and will
contain such information and
disclosure as such attorney-in-fact, in her discretion, deems necessary or
desirable; neither the Company nor any
such attorneys-in-fact assumes (i) any liability for the undersigned's
responsibility to comply with the
requirement of the Exchange Act, (ii) any liability of the undersigned for any
failure to comply with such
requirements, or (iii) any obligation or liability of the undersigned for profit
disgorgement under
Section 16(b) of the Exchange Act; and this Power of Attorney does not relieve
the undersigned from responsibility
for compliance with the undersigned's obligations under the Exchange Act,
including without limitation the
reporting requirements under Section 16 of the Exchange Act.
This Power of Attorney shall remain in effect until it is revoked in
writing or the undersigned has ceased
to serve as an executive officer or director of LeMaitre Vascular, Inc.
IN WITNESS WHEREOF, this Power of Attorney has been signed as of August
24, 2015.
/s/ Michael T. Wijas
Print Name: Michael T. Wijas
