SECURITIES AND EXCHANGE COMMISSION
WASHINGTON, D.C. 20549
FORM 15
CERTIFICATION AND NOTICE OF TERMINATION OF REGISTRATION UNDER SECTION 12(G)
OF THE SECURITIES EXCHANGE ACT OF 1934 OR SUSPENSION ON DUTY TO FILE REPORTS
UNDER SECTIONS 13 AND 15(D) OF THE SECURITIES EXCHANGE ACT OF 1934.
COMMISSION FILE NUMBER 1-11538
HEALTHSOURCE, INC.
(EXACT NAME OF REGISTRANT AS SPECIFIED IN ITS CHARTER)
TWO COLLEGE PARK DRIVE, HOOKSETT, NH 03106
(ADDRESS, INCLUDING ZIP CODE, AND TELEPHONE NUMBER, INCLUDING AREA CODE, OF
REGISTRANT'S PRINCIPAL EXECUTIVE OFFICES)
COMMON STOCK PURCHASE RIGHTS
(TITLE OF EACH CLASS OF SECURITIES COVERED BY THIS FORM)
COMMON STOCK, $.10 PAR VALUE PER SHARE
5% CONVERTIBLE SUBORDINATED NOTES DUE 2003
(TITLES OF ALL OTHER CLASSES OF SECURITIES FOR WHICH A DUTY TO FILE REPORTS
UNDER SECTION 13(A) OR 15(D) REMAINS)
PLEASE PLACE AN X IN THE BOX(ES) TO DESIGNATE THE APPROPRIATE RULE
PROVISION(S) RELIED UPON TO TERMINATE OR SUSPEND THE DUTY TO FILE REPORTS:
RULE 12G-4(A)(1)(I) (X) RULE 12H-3(B)(1)(I) (X)
RULE 12G-4(A)(1)(II)( ) RULE 12H-3(B)(1)(II)( )
RULE 12G-4(A)(2)(I) ( ) RULE 12H-3(B)(2)(I) ( )
RULE 12G-4(A)(2)(II)( ) RULE 12H-3(B)(2)(II)( )
RULE 15D-6 ( )
APPROXIMATE NUMBER OF HOLDERS OF RECORD AS OF THE CERTIFICATION OR NOTICE
DATE: 0
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PURSUANT TO THE REQUIREMENTS OF THE SECURITIES EXCHANGE ACT OF 1934,
HEALTHSOURCE, INC. HAS CAUSED THIS CERTIFICATION/NOTICE TO SIGNED ON ITS
BEHALF BY THE UNDERSIGNED DULY AUTHORIZED PERSON.
HEALTHSOURCE, INC.
DATE: JUNE 30, 1997 BY: /s/ Johan M. DeJong
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Johan M. DeJong, Counsel
Instruction: This form is required by Rules 12g-4, 12h-3 and 15d-6 of the
General Rules and Regulations under the Securities Exchange Act of 1934.
The registrant shall file with the Commission three copies of Form 15, one
of which shall be manually signed. It may be signed by an officer of the
registrant, by counsel or by any other duly authorized person. The name and
title of the person signing the form shall be typed or printed under the
signature.
