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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)
Jakimcius Andrew A.
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(Last) (First) (Middle)
4355 Varsity Drive Suite E
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(Street)
Ann Arbor Michigan 48108
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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)
[_] Director [_] 10% Owner
[X] Officer (give title below) [_] Other (specify below)
Executive Vice President of Operations
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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 30,531(1) D
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Reminder: Report on a separate line for each class of securities beneficially
owned directly or indirectly.
(1) This number includes 642 shares of callable common stock that will be issued
upon the automatic exercise of warrants at the closing of the Company's
initial public offering.
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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 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 (1) 5/9/04 Callable Common 13,334 $ .07 D
Stock
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Options (2) 1/15/08 Callable Common 4,800 $ .37 D
Stock
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Options (3) 4/15/08 Callable Common 42,000 $ 2.00 D
Stock
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Explanation of Responses:
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(1) These options were issues on May 9, 1997 and will vest upon completion of
the Company's initial public offering.
(2) These options were issued on January 15, 1998 and will vest as follows:
1,600 on 1/15/01; 1,600 on 1/15/02 and 1,600 on 1/15/03.
(3) These options were issued April 15, 1998. Of these options, 16,800 are
currently exercisable and the remaining options will vest as follows:
8,400 on 4/15/01; 8,400 on 4/15/02 and 8,400 on 4/15/03.
/s/ Andrew A. Jakimcius 5/4/00
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Signature of Reporting Person(1) Date
Andrew A. Jakimcius
(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)
