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- -------- UNITED STATES SECURITIES AND EXCHANGE COMMISSION -----------------------------
FORM 3 WASHINGTON, D.C. 20549 OMB APPROVAL
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INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES OMB Number: 3235-0104
Expires: February 1, 1998
Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934, Estimated average burden
Section 17(a) of the Public Utility Holding Company Act of 1935 or hours per response .... 0.5
(Print or Type Responses) 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 Re- 4. Issuer Name AND Ticker or Trading Symbol
quiring Statement
KUBAN MICHAEL (Month/Day/Year) CHOICETEL COMMUNICATIONS, INC. (PHON)
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(Last) (First) (Middle) 1/29/98 5. Relationship of Reporting Person(s) 6. If Amendment, Date
----------------------- to Issuer (Check all applicable) of Original
3. IRS or Social Se- Director 10% Owner (Month/Day/Year)
c/o CHOICETEL COMMUNICATIONS, INC. curity Number of ---- ----
9724 10th AVENUE NORTH Reporting Person Officer (give Other (specify ---------------------
- ------------------------------------------------- (Voluntary) title below) X below) 7. Individual or
(Street) ---- ---- Joint/Group Filing
(Check Applicable
Corporate Controller Line)
--------------------------- Form filed by One
X Reporting Person
---
Form filed by
More than One
Reporting Person
PLYMOUTH MINNESOTA 55441 ---
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(City) (State) (Zip) TABLE I -- NON-DERIVATIVE SECURITIES BENEFICIALLY OWNED
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1. Title of Security 2. Amount of Securities 3. Ownership 4. Nature of Indirect Beneficial
(Instr. 4) Beneficially Owned Form: Direct Ownership (Instr. 5)
(Instr. 4) (D) or Indirect
(I) (Instr. 5)
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. (Over)
(Print or Type Response) SEC 1473 (7-97)
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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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1. Title of Derivative Security 2. Date Exer- 3. Title and Amount of Securities 4. Conver- 5. Owner- 6. Nature of Indirect
(Instr. 4) cisable and Underlying Derivative Security sion or ship Beneficial
Expiration (Instr. 4) Exercise Form of Ownership
Date Price of Deriv- (Instr. 5)
(Month/Day/ Deri- ative
Year) vative Security:
-------------------------------------------------- Security Direct
Amount (D) or
Date Expir- or Indirect
Exer- ation Title Number (I)
cisable Date of
Shares (Instr. 5)
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EMPLOYEE STOCK OPTION (right to buy) (1) 1/28/03 COMMON STOCK 10,000 $3.75 D
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Explanation of Responses:
(1) The option vests in three equal annual installments beginning on January 29, 1999.
/s/ Michael Kuban February 2, 1998
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** Intentional misstatements or omissions of facts constitute Federal Michael Kuban Date
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, Page 2
SEE Instruction 6 for procedure. SEC 1473 (3/91)
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.
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