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FORM 3
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U.S. SECURITIES AND EXCHANGE COMMISSION
WASHINGTON, DC 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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<S> <C> <C> <C>
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1. Name and Address of Reporting Person 2. Date of Event Requiring 4. Issuer Name and Ticker or 6. If Amendment, Date
Statement Trading Symbol of Original
HENRY E. BAKER (Month/Day/Year) VERMONT PURE HOLDINGS, LTD. (VPS) (Month/Day/Year)
---------------------------------------- 10/05/00 ----------------------------------
(Last) (First) (Middle) ---------------------------- 5. Relationship of Reporting -----------------------
c/o VERMONT PURE HOLDINGS, LTD. 3. IRS Identification Person to Issuer 7. Individual or Joint/
ROUTE 66, P.O. BOX C Number of Reporting (Check all applicable) Group Filing (Check
CATAMOUNT INDUSTRIAL PARK Person, if an Entity X Director 10% Owner applicable line)
---------------------------------------- (Voluntary) ----- ----- X Form filed by
(Street) Officer Other ----- One Reporting
----- (give ----- (specify Person
RANDOLPH VT 05060 title below) below) Form filed by
----------------------------------------------------------------------------------------------------------- ----- More than One
(City) (State) (Zip) Reporting Person
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TABLE I -- NON-DERIVATIVE SECURITIES BENEFICIALLY OWNED
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1. Title of Security 2. Amount of Securities 3. Ownership Form: 4. Nature of Indirect
(Instr. 4) Beneficially Owned Direct (D) or Beneficial
(Instr. 4) Indirect (I) Ownership (Instr. 5)
(Instr. 5)
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COMMON STOCK 1,065,219 D
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. (Over)
(Print or Type Responses)
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FORM 3 (CONTINUED) TABLE II -- DERIVATIVE SECURITIES BENEFICIALLY OWNED
(E.G., PUTS, CALLS, WARRANTS, OPTIONS, CONVERTIBLE SECURITIES)
<S> <C> <C> <C> <C> <C>
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1. Title of Derivative Security 2. Date 3. Title and Amount of 4. Conver- 5. Owner- 6. Nature of Indirect
(Instr. 4) Exercisable and Securities Underlying sion or ship Beneficial Ownership
Expiration Date Derivative Security Exercise Form of (Instr. 5)
(Month/Day/ (Instr. 4) Price of Deriv-
Year) Deri- ative
vative Security:
Security Direct
------------------------------------------------- (D) or
Date Expira- Amount or Indirect
Exercis- tion Title Number (I)
able Date of Shares (Instr.
5)
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None
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Explanation of Responses:
Henry E. Baker 10/16/00
**Intentional misstatements or omissions of facts constitute Federal Criminal ------------------------------- ------------------
Violations. See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). **Signature of Reporting Person Date
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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