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OMB APPROVAL
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OMB Number 3235-0104
Expires: 12-31-2001
Estimated average burden
hours per response ....... 0.5
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U.S. SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
FORM 3
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*
Gorman Thomas Y.
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(Last) (First) (Middle)
15423 East Batavia Drive
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(Street)
Aurora CO 80011
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(City) (State) (Zip)
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2. Date of Event Requiring Statement (Month/Day/Year)
10/15/99
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3. IRS Identification Number of Reporting Person, if an Entity (Voluntary)
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4. Issuer Name and Ticker or Trading Symbol
IN STORE MEDIA SYSTEMS, INC./ISMS
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5. Relationship of Reporting Person to Issuer
(Check all applicable)
[_] Director [_] 10% Owner
[X] Officer (give title below) [_] Other (specify below)
Chief Financial Officer
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6. If Amendment, Date of Original (Month/Day/Year)
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Table I -- Non-Derivative Securities Beneficially Owned
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3. Ownership Form:
2. Amount of Securities Direct (D) or
1. Title of Security Beneficially Owned Indirect (I) 4. Nature of Indirect Beneficial Ownership
(Instr. 4) (Instr. 4) (Instr. 5) (Instr. 4)
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<S> <C> <C> <C>
Common Stock ($.001 par value) 37,500 D
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Reminder: Report on a separate line for each class of securities beneficially
owned directly or indirectly.
(Over)
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FORM 3 (continued)
Table II -- Derivative Securities Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
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5. Owner-
3. Title and Amount of Securities ship
Underlying Derivative Security Form of
2. Date Exercisable (Instr. 4) Derivative
and Expiration Date --------------------------------- 4. Conver- Security:
(Month/Day/Year) Amount sion or Direct 6. Nature of
---------------------- or Exercise (D) or Indirect
Date Expira- Number Price of Indirect Beneficial
1. Title of Derivative Exer- tion of Derivative (I) Ownership
Security (Instr. 4) cisable Date Title Shares Security (Instr. 5) (Instr. 5)
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<S> <C> <C> <C> <C> <C> <C> <C>
Options granted under
Incentive Bonus Plan * * Common Stock 1,000,000 $1.00 D
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Explanation of Responses:
* Option were granted on 9/20/98 and revised on 6/7/99; 50,000 shares vest
one year from initial date of grant; 50,000 shares vest when equity
financing is completed cumulative from employment date; and the remaining
900,000 shares vest in 100,000 share increments pursuant to certain goals
reached as more fully described in Reporting Person's Incentive Bonus Plan.
/S/ Thomas Y. Gorman 2-10-2000
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**Signature of Reporting Person Date
** 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 provided is insufficient, see Instruction 6 for procedure.
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