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FORM 3
U.S. 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,
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(1)
Mitchell Daniel J.
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(Last) (First) (Middle)
4430 Arapahoe Avenue, Suite 220
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(Street)
Boulder CO 80303
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(City) (State) (Zip)
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2. Date of Event Requiring Statement (Month/Day/Year)
May 4, 2000
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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
Genomic Solutions Inc., Nasdaq National Market System (GNSL)
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5. Relationship of Reporting Person to Issuer
(Check all applicable)
[X] Director [_] 10% Owner
[_] Officer (give title below) [_] Other (specify below)
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6. If Amendment, Date of Original (Month/Day/Year)
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7. 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
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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>
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Callable Common Stock 1,844,739(1) 1 (2)
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Reminder: Report on a separate line for each class of securities beneficially
owned directly or indirectly
(1) See Exhibit A.
(2) These shares are held in the name of American Healthcare Fund II, and are
attributable to Mr. Mitchell as he is a general partner of Capital Health
Ventures, the general partner of American Healthcare Fund II.
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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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<CAPTION>
5. Owner-
3. Title and Amount of Securities ship
Underlying Derivative Securities 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 (3) 1/15/2008 Callable Common 10,000 $. 37 1 (4)
Stock
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Options (5) 1/15/2009 Callable Common 10,000 $2.00 1 (4)
Stock
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Explanation of Responses:
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(3) These options were issued on January 15, 1998 and vested after one year.
(2) These options are held in the name of American Healthcare Fund II, and
are attributable to Mr. Mitchell as he is a general partner of Capital
Health Ventures, the general partner of American Healthcare Fund II.
(3) These options were issued on January 15, 1999 and vested after one year.
/s/ Daniel J. Mitchell 5/4/2000
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Signature of Reporting Person(1) Date
Daniel J. Mitchell
(1)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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(Print or Type Responses)
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Exhibit A
This number represents shares of Series B, C, and D Preferred Stock, common
stock and warrants that automatically convert into or are automatically
exercised for callable common stock at the closing of the Company's initial
public offering as follows:
400,353 shares of Series B preferred which convert into 1,213,191 shares of
callable common stock
342,857 shares of Series C Preferred which convert into 342,857 shares of
callable common stock
25,000 shares of Series D Preferred which convert into 25,000 shares of
callable common stock
177,352 shares of Common Stock which convert into 177,352 shares of callable
common stock
86,339 Warrants which convert into 86,339 shares of callable common stock
