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- -------- UNITED STATES SECURITIES AND EXCHANGE COMMISSION -----------------------------
FORM 3 WASHINGTON, D.C. 20549 OMB APPROVAL
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INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES OMB Number: 3235-0104
Expires: September 30, 1998
Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934, Estimated average burden
Section 17(a) of the Public Utility Holding Company Act of 1935 or hours per response .... 0.5
(Print or Type Responses) Section 30(f) of the Investment Company Act of 1940 -----------------------------
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1. Name and Address of Reporting Person* 2. Date of Event Re- 4. Issuer Name AND Ticker or Trading Symbol
quiring Statement
Henrickson Mark (Month/Day/Year) WaterPur International Inc. - WPUR
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(Last) (First) (Middle) May 10, 1999 5. Relationship of Reporting Person(s) 6. If Amendment, Date
----------------------- to Issuer (Check all applicable) of Original
3. IRS or Social Se- X Director X 10% Owner (Month/Day/Year)
curity Number of ---- ----
6701 B Oldfield Road Reporting Person Officer (give Other (specify ---------------------
- ------------------------------------------------- (Voluntary) X title below) below) 7. Individual or
(Street) ---- ---- Joint/Group Filing
(Check Applicable
Chief Executive Officer Line)
--------------------------- Form filed by One
X Reporting Person
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Form filed by
More than One
Reporting Person
Saanichton, B.C., Canada V8M 2AL ---
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(City) (State) (Zip) TABLE I -- NON-DERIVATIVE SECURITIES BENEFICIALLY OWNED
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1. Title of Security 2. Amount of Securities 3. Ownership 4. Nature of Indirect Beneficial
(Instr. 4) Beneficially Owned Form: Direct Ownership (Instr. 5)
(Instr. 4) (D) or Indirect
(I) (Instr. 5)
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. (Over)
* If the form is filed by more than one reporting person, SEE Instruction 5(b)(v). SEC 1473 (7-97)
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 CONTROL NUMBER.
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FORM 3 (CONTINUED) TABLE II - DERIVATIVE SECURITIES BENEFICIALLY OWNED (E.G., PUTS, CALLS, WARRANTS, OPTIONS, CONVERTIBLE
SECURITIES)
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1. Title of Derivative Security 2. Date Exer- 3. Title and Amount of Securities 4. Conver- 5. Owner- 6. Nature of Indirect
(Instr. 4) cisable and Underlying Derivative Security sion or ship Beneficial
Expiration (Instr. 4) Exercise Form of Ownership
Date Price of Deriv- (Instr. 5) **
(Month/Day/ Deri- ative
Year) vative Security:
-------------------------------------------------- Security* Direct
Amount (D) or
Date Expir- or Indirect
Exer- ation Title Number (I)
cisable Date of
Shares (Instr. 5)
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Series B 5/10/99 n/a Common 218,833,000 I
Convertible Stock Stock
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Explanation of Responses:
See below.
/s/ Mark Henrickson 5/19/99
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**Intentional misstatements or omissions of facts constitute Federal **Signature of Reporting Person Date
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 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. Page 2
SEC 1473 (7-97)
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* Each share of Series B Convertible Stock is convertible into 1,000 shares
of the Company's Common Stock.
** Mr. Henrickson owns approximately 23% of Duck Marine Systems Inc. which
in turn is the owner of 218,833 shares of Series B Convertible Stock which
is convertible into 218,833,000 shares of the Company's Common Stock.
