UNITED STATES SECURITIES AND EXCHANGE COMMISSION
WASHINGTON, D.C. 20549
FORM 3
INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES
1. Name and Address of Reporting Person:
John A. Dore
286 Sheridan Road
Winnetka, Illinois 60093
2. Date of Event Requiring Statement (Month/Day/Year)
August 17, 2000
3. I.R.S. Identification Number of Reporting Person, if an entity
(Voluntary):
4. Issuer Name and Ticker of Trading Symbol:
American Country Holdings Inc.
5. Relationship of Reporting Person(s) to Issuer (Check all
applicable):
(x) Director
(x) Officer (give title below)
( ) 10% Owner
( ) Other (specify below)
Co-Chairman of the Board, Director and Chief Executive 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
<TABLE>
<CAPTION>
NON-DERIVATIVE SECURITIES BENEFICIALLY OWNED
<S> <C> <C> <C>
2. Amount of Securities 3. Ownership Form: 4. Nature of Indirect
1. Title of Security Beneficially Owned (Inst. Direct (D) or Indirect Beneficial Ownership
(Instr. 4) 4) (I) (Instr. 5) (Instr. 5)
-------------------- ------------------------- ---------------------- ---------------------
Common Stock, $.01 par value 61,000 D
Common Stock, $.01 par value 2,000 I IRA
Common Stock, $.01 par value 4,000 I Keogh
Common Stock, $.01 par value 2,600 I As trustee for
Christopher L. Dore
Common Stock, $.01 par value 3,565 I As trustee for John A.
Dore II
</TABLE>
<TABLE>
TABLE II - DERIVATIVE SECURITIES BENEFICIALLY OWNED (E.G., PUTS,
CALLS, WARRANTS, OPTIONS, CONVERTIBLE SECURITIES)
<CAPTION>
5.
Ownership
4. Conver- Form of 6. Nature
sion or Derivative of Indirect
1. Title of 3. Title and Amount of Exercise Security: Beneficial
Derivative 2. Date Exercisable Securities Underlying Price of Direct (D) Ownership
Security and Expiration Date Derivative Security (Instr. Derivative or Indirect (Instr. 5)
(Instr. 4) (Month/Day/Year) 4) Security (I) (Instr. ----------
----------- ------------------- ------------------- ---------- 5)
-----------
Date Amount or
Exer- Expira- Number of
cisable tion Date Title Shares
-------- -------- ------ ---------
<S> <C> <C> <C> <C> <C> <C>
Option 8/17/00 8/16/10 Common Stock, 100,000 $2.88 D
$.01 par value
Option 8/17/03* 8/16/10 Common Stock, 300,000 $2.88 D
$.01 par value
*These options vest at 33-1/3% per year and become fully exercisable three years after the date of grant.
</TABLE>
SIGNATURE OF REPORTING PERSON:
/s/ John A. Dore
-----------------------
John A. Dore
Dated: September 5, 2000
