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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.
Romo, Jr. | Adam | E. | |
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Last | First | Middle |
Santa Barbara | CA | 93103 | |
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City | State | Zip |
2. Date of Event Requiring Statement (Month/Day/Year)
January 4, 2001
3. IRS Identification Number of Reporting Person, if an Entity (Voluntary)
4. Issuer Name and Ticker or Trading Symbol
The Plastic Surgery Company PSU
5. Relationship of Reporting Person to Issuer (Check all applicable).
[ ] Director
[ ] 10% Owner
[X] Officer (give title below)
[ ] Other (specify below)
Chief Financial Officer
6. If Amendment, Date of Original (Month/Day/Year)
7. Individual or Joint/Group Filing (Check applicable line)
[X] Form Filed by One Reporting Person
[ ] Form Filed by More than One Reporting Person
============================ == ========================== == =========================== ==== ======================= 1. Title of Security 2. Amount of 3. Ownership Form: 4. Nature of (Instr. 4) Securities Beneficially Direct (D) or Indirect (I) Indirect Beneficial Owned (Instr. 4) (Instr. 5) Ownership (Instr. 5) ---------------------------- -------------------------- --------------------------- ----------------------- ============================ == ========================== == =========================== ==== =======================
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)
Form 3 (continued)
=================================================================================================================================== 1. Title of 2. Date 3. Title and 4. 5. Ownership 6. Nature of Derivative Security Exer-cisable and Amount Underlying Conversion Form of Indirect (Instr. 4) Expiration Date Derivative Security or Exercise Derivative Beneficial (Month/Date/Year) (Instr. 4) Price of Security: Ownership Derivative Direct (D) (Instr. 5) Date Exer- Amount Security or Indirect Expir- ciable or Number (I) (Instr. 5) ation Date Title of Shares Date ----------------------- ------- ------- ------------------------- -------------- --------------- --------------- Common Stock * * Common Stock 100,000 $1.875 D ===================================================================================================================================
Explanation of Reponses:
* Vested 25,000 shares annually beginning 1/4/02, 1/4/03, 1/4/04 and 1/5/04.
Date: January 17, 2001 | |||
By:/s/ Adam E. Romo, Jr. | |||
**Signature of Reporting Person |
**International 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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