FORM 5 OMB APPROVAL
[ ] CHECK BOX IF NO LONGER SUBJECT OMB Number 3235-0362
TO SECTION 16. FORM 4 OR FORM 5 Expires: February 1, 1994
OBLIGATIONS MAY CONTINUE. SEE Estimated average burden
INSTRUCTION 1(b). hours per response .. 1.0
[ ] FORM 3 HOLDINGS REPORTED
[XX] FORM 4 TRANSACTIONS REPORTED
U.S. SECURITIES AND EXCHANGE COMMISSION
WASHINGTON, D.C. 20549
ANNUAL 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
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1. Name and Address of Reporting Person
Conway Peter R.
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(Last) (First) (Middle)
501 Old Territorial Road
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(Street)
Chatfield MN 55923
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(City) (State) (Zip)
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2. Issuer Name and Ticker or Trading Symbol
Rochester Medical Corporation (ROCM)
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3. IRS or Social Security Number of Reporting Person (Voluntary)
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4. Statement for Month/Year
JAN 96
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5. If Amendment, Date of Original (Month/Year)
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6. Relationship of Reporting Person to Issuer
(Check all applicable)
[ ] 10% Owner
[X] Director
[ ] Officer (give title below)
[ ] Other (specify below)
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FORM 5 (continued)
<TABLE>
<CAPTION>
TABLE I -- NON-DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF, OR BENEFICIALLY OWNED
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1. 2. 3. 4. 5. 6. 7.
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Owner-
Amount of ship
Trans- Securities Acquired (A) Securities Form:
action or Disposed of (D) Beneficially Direct Nature of
Date Trans- (Instr. 3, 4 and 5) Owned at End (D) or Indirect
Title of (Month/ action ---------------------------- of Month Indirect Beneficial
Security Day/ Code Amount (A) or Price (Instr. (I) Ownership
(Instr. 3) Year) (Instr. 8) (D) 3 and 4) (Instr. 4) (Instr. 4)
- --------------------- -------- ---------- ----------- ------ --------- ----------- ---------- ----------
<S> <C> <C> <C> <C> <C> <C> <C> <C>
Common Stock 75,200 D
</TABLE>
Reminder: Report on a separate line for each class of securities beneficially
owned directly or indirectly. (Print or Type Responses)
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<PAGE>
FORM 5 (CONTINUED)
<TABLE>
<CAPTION>
TABLE II -- DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF, OR BENEFICIALLY OWNED
(E.G. PUTS, CALLS, WARRANTS, OPTIONS, CONVERTIBLE SECURITIES)
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1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
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Title and Ownership
Number of Date Exer- Amount of of
Derivative cisable and Underlying Number of Deriv-
Securities Expiration Securities Price Derivative ative
Conver- Acquired (A) Date (Month/ (Instr. 3 of Securities Security:
sion or Trans- or Disposed Day/Year) and 4) Deriv- Benefi- Direct
Exercise action Trans- of (D) -------------- -------------- ative cially (D) or Nature of
Title of Price of Date action (Instr. 3, Date Amount Secur- Owned at Indirect Indirect
Derivative Deriv- (Month/ Code 4 and 5) Exer- Expir- or Num- ity End of (I) Beneficial
Security ative Day/ (Instr. ---------- cis- ation ber of (Instr. Month (Instr. Ownership
(Instr. 3) Security Year) 8) (A) (D) able Date Title Shares 5) (Instr. 4) 4) (Instr. 4)
- ---------- -------- -------- -------- ---- ---- ------- ----- ----- ------ ------ ---------- -------- ----------
<S> <C> <C> <C> <C> <C> <C> <C> <C> <C> <C> <C> <C> <C>
Common
Option $20.00 1/16/97 A 1,000 1/16/97 9/30/06 Stock 1,000 (1) 25,000 D
</TABLE>
(1) Annual automatic grant to non-employee director.
Explanation of Responses:
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/s/ Peter R. Conway 3/5/97
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** Signature of Reporting Person Date
** 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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