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FORM 3
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OMB APPROVAL
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OMB Number [ILLEGIBLE]
Expires: October 31, 2001
Estimated average burden
hours per response ....... 0.5
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
INITIAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP
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
(Print or Type Responses)
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1. Name and Address of Reporting Person*
Gramlich, David A.
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(Last) (First) (Middle)
21274-87 87 Place
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(Street)
Langley, B.C. Canada V1M 1Z8
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(City) (State) (Zip)
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2. Date of Event Requiring Statement (Month/Day/Year)
July 31, 1999 (became reporting entity)
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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
LOM Medical International Inc. LOMM
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5. Relationship of Reporting Person(s) 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)
________________________________________________________________________________
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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<TABLE>
<CAPTION>
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>
common shares 45,000 direct N/A
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</TABLE>
<PAGE>
Table II -- Derivative Securities Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
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<TABLE>
<CAPTION>
5. Owner-
3. Title and Amount of Securities ship
Underlying Derivative Security 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>
N/A N/A N/A N/A N/A N/A N/A N/A
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</TABLE>
Reminder: Report on a separate line for each class of securities beneficially
owned directly or indirectly.
Explanation of Responses:
/s/ David A. Gramlich 03/06/00
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**Signature of Reporting Person Date
* If the form is filed by more than one reporting person, see Instruction
5(b)(v).
** 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.
