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Next: NATIONAL SCIENTIFIC CORP/AZ, 3, 2000-12-12 |
FORM 3 |
UNITED STATES SECURITIES AND EXCHANGE
COMMISSION |
OMB APPROVAL OMB NUMBER: 3235-0104 Expires: October 31, 2001 Estimated average burden hours per response...............0.5 |
(Print or Type Responses) |
1. Name and
Address of Reporting Person* __________________________________ (Last) (First) (Middle) Grollman Michael A ________________________________ (Street) 4455 East Camelback Road Ste E-160 ________ _________ ____ (City) (State) (Zip) Phoenix AZ 85018 |
2. Date of
Event Requiring Statement (Month/Day/Year) 12/01/2000 |
4. Issuer Name
and Ticker or Trading Symbol National Scientific Corporation NSCT |
|
5.
Relationship of Reporting Person(s) to Issuer (Check all applicable) [ X] Director [ ] 10% Owner [ X] Officer (give title [ ] Other (specify below) below) Chief Operating Officer, Executive VP |
6. If Amendment, Date of
Original (Month/Day/Year) |
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3. I.R.S. Identification Number of Reporting Person, if an entity (voluntary) 86-0837077 |
7. Individual or
Joint/Group Filing (Check Applicable Line) [ 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) |
NSCT Common Stock | 100,035 | D | |
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 (7-97)
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 (Month/Date/Year) |
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 |
||||
NSCT Options | 12/1/2000 | 12/1/2010 | NSCT Common Stock | 450,000 | $1.84 | D | |
NSCT Options | 12/1/2000 | 12/1/2010 | NSCT Common Stock | 50,000 | $1.84 | D | |
/s/ Michael A. Grollman | 12/8/2000 | ||
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**Signature of Reporting Person | Date |
Explanation of Responses:
** Intentional misstatements or omissions of facts constitute
Federal Criminal Violations.
See 18 U.S.C. 1001 and 15 U.S.C. 7811(a).
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
SEC 1473(7-97)
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