FORM 3 U.S. SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
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 1990
- -------------------------------------------------------------------------------
1. Name and Address of Reporting Person
Davis, Roger D.
(Last) (First) (Middle)
102 West 500 South, Suite 300
- ----------------------------------------
(Street)
Salt Lake City, Utah 84101
- ----------------------------------------------
(City) (State) (Zip)
2. Date of Event Requiring
Statement
(Month/Day/Year)
01/31/97
- ----------------------------------
3. IRS or Social Security Number
of Reporting Person (Voluntary)
4. Issuer Name and Ticker of Trading Symbol
Celtic Investment, Inc.
- ----------------------------------------------
5. Relationship of Reporting Person to Issuer
(Check all applicable)
____ Director _X__ 10% Owner
_X__ Officer (give ____ Other (specify
title below) below)
Secretary, Treasurer, & V.P. Sales & Marketing
Salt Lake Mortgage Corp.
---------------------------------------------
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>
TABLE I - NON-DERIVATIVE ACQUIRED, DISPOSED OF, OR BENEFICIALLY
OWNED
- -------------------------------------------------------------------------------------------------------------
<S> <S> <S>
1. Title of Security 2. Amount of Securities 3. Ownership Form: Direct
(Instr. 4) Beneficially Owned (D) or Indirect (I) (Instr. 5)
(Instr. 4)
- -------------------------------------------------------------------------------------------------------------
Common Stock Par Value 544,450 (i) D
.01 per share
- -------------------------------------------------------------------------------------------------------------
4. Nature of Indirect Beneficial Ownership
(Instr. 5)
- -------------------------------------------------------------------------------------------------------------
- --------------------------------------------------------------------------------------------------------------------------
</TABLE>
Reminder: Report on a separate line for each class of securities beneficially
owned directly or indirectly.
(Print or Type Responses)
(Over)
<PAGE>
FORM 3 - (continued)
TABLE II - DERIVATIVE SECURITIES BENEFICIALLY OWNED
(E.G., PUTS, CALLS, WARRANTS, OPTIONS, CONVERTIBLE SECURITIES)
1. Title of Derivative Security
(Instr. 4)
- ---------------------------------
Employee Stock Options
(Right to Buy)
- ---------------------------------
Employee Stock Options
(Right to Buy)
- ---------------------------------
2. Date Exercisable
and Expiration Date
(Month/Day/Year)
Date Expira-
Exer- tion
cisable Date
1/31/98 (ii) 1/31/2003 (ii)
- ---------------------------------
6/30/99 (iii) 6/30/2007 (iii)
- ---------------------------------
3. Title and Amount of Securities
Underlying Derivative Security
(Instr. 4)
Title Amount
or
Number
of
Shares
- ------------------------------------
Common Stock 150,000
- ------------------------------------
Common Stock 350,000
- ------------------------------------
- ------------------------------------
4. Conversion
of Exercise
Price of
Derivative
Security
- -----------------------------------
3.00
- -----------------------------------
3.00
- -----------------------------------
- -----------------------------------
5. Ownership Form of
Derivative
Security:
Direct (D) or
Indirect (I)
(Instr. 5)
- -----------------------------------
D
- -----------------------------------
D
- -----------------------------------
- -----------------------------------
6. Nature of Indirect
Beneficial
Ownership
(Instr. 5)
- -----------------------------------
N/A
- -----------------------------------
N/A
- -----------------------------------
- -----------------------------------
Explanation of Responses:
(i) 250,000 shares have been placed in in escrow and may be requred to be
returned to the issuer if (1) certain conditions are not met relating to the
fiancial performance of one of the issuer's business lines or (2) if certain
other events do not occur.
(ii) 75,000 Options will vest on each of January 31, 1998 and Janury 31, 1999
and expire five years thereafter.
(iii) Subject to the satisfaction of certain financial perfomance criteria,
48,611 Options will vest on June 30, 2001, and 68,055 Options will vest on
June 30, 2002. If vested, the Options will expire five years after thereafter.
++Intentional misstatements or omissions of facts constitute Federal Criminal
Violations.
See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a).
/s/ Roger D. Davis 2/10/97
- ------------------------------------- ---------------
++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.
Potential persons who are to respond to the collection of information contained
in this form are not required to respond unless the form displays a currently
valid OMB number.
