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OMB APPROVAL
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OMB Number 3235-0287
Expires: September 30, 1999
Estimated average burden
hours per response ....... .05
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U.S. SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
FORM 4
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
[_] Check box if no longer subject to Section 16. Form 4 or Form 5 obligations
may continue. See Instruction 1(b).
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1. Name and Address of Reporting Person*
Grossman Richard
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(Last) (First) (Middle)
101 East 52nd Street
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(Street)
New York New York 10022
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(City) (State) (Zip)
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2. Issuer Name and Ticker or Trading Symbol
Medjet Inc. (MDJT)
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3. IRS Identification Number of Reporting Person, if Entity (Voluntary)
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4. Statement for Month/Year
1/00
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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)
[_] Director [X] 10% Owner
[_] Officer (give title below) [_] Other (specify below)
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7. Individual or Joint/Group Filing (Check applicable line)
[_] Form filed by one Reporting Person
[X] Form filed by more than one Reporting Person
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Table I -- Non-Derivative Securities Acquired, Disposed of,
or Beneficially Owned
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<TABLE>
<CAPTION>
6.
4. 5. Owner-
Securities Acquired (A) or Amount of ship
3. Disposed of (D) Securities Form: 7.
Transaction (Instr. 3, 4 and 5) Beneficially Direct Nature of
2. Code ------------------------------- Owned at End (D) or Indirect
1. Transaction (Instr. 8) (A) of Month Indirect Beneficial
Title of Security Date ------------ Amount or Price (Instr. 3 (I) Ownership
(Instr. 3) (mm/dd/yy) Code V (D) and 4) (Instr.4) (Instr. 4)
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<S> <C> <C> <C> <C> <C> <C> <C> <C> <C>
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</TABLE>
Reminder: Report on a separate line for each class of securities beneficially
owned directly or indirectly.
(Print or Type Responses)
(Over)
SEC 1474(8-92)
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FORM 4 (continued)
Table II -- Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
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<TABLE>
<CAPTION>
10.
9. Owner-
Number ship
of Form
2. Deriv- of
Conver- 5. 7. ative Deriv- 11.
sion Number of Title and Amount Secur- ative Nature
or Derivative 6. of Underlying 8. ities Secur- of
Exer- 4. Securities Date Securities Price Bene- ity: In-
cise 3. Trans- Acquired (A) Exercisable and (Instr. 3 and 4) of ficially Direct direct
Price Trans- action or Disposed Expiration Date ---------------- Deriv- Owned (D) or Bene-
1. of action Code of(D) (Month/Day/Year) Amount ative at End In- ficial
Title of Deriv- Date (Instr. (Instr. 3, ---------------- or Secur- of direct Owner-
Derivative ative (Month/ 8) 4 and 5) Date Expira- Number ity Month (I) ship
Security Secur- Day/ ------ ------------ Exer- tion of (Instr. (Instr. (Instr. (Instr.
(Instr. 3) ity Year) Code V (A) (D) cisable Date Title Shares 5) 4) 4) 4)
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<S> <C> <C> <C> <C> <C> <C> <C> <C> <C> <C> <C> <C> <C> <C>
Series B Convertible Common
Preferred Stock $1.25 1/31/00 J(1) 280 Immed. Stock 28,000 (2) 520 (D) (3)
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Series B Convertible Common
Preferred Stock $1.25 1/31/00 J(1) 266 Immed. Stock 26,600 (2) 494 (D) (4)
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Series B Convertible Common
Preferred Stock $1.25 1/31/00 J(1) 4200 Immed. Stock 420,000 (2) 7,800 (I) (5)(6)
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Common
Warrants $3.50 1/31/00 J(1) 28,000 1/31/00 12/3/04 Stock 28,000 (2) 52,000 (D) (3)
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Common
Warrants $3.50 1/31/00 J(1) 26,600 1/31/00 12/3/04 Stock 26,600 (2) 49,400 (D) (4)
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Common
Warrants $3.50 1/31/00 J(1) 595,000 1/31/00 12/3/04 Stock 595,000 (2) 1,105,000 (I) (6)(7)
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</TABLE>
Explanation of Responses:
(1) On January 31, 2000 the sale reported to have occurred on December 6, 1999
was partially rescinded.
(2) The reported securities are included within Medjet Units with a price of
$125 per Unit. Each Unit consists of one share of Series B Convertible
Preferred Stock, convertible into one hundred shares of Common Stock, and
one hundred warrants, each exercisable to purchase one share of Common
Stock. The securities held by Adam Smith & Company, Inc. were acquired
pursuant to an investment banking agreement.
(3) These securities are owned solely by Richard and Ana Grossman JTWROS, who
are members of a "group" with Orin Hirschman for purposes of Section 13(d)
of the Exchange Act.
(4) These securities are owned solely by Orin Hirschman.
(5) These securities are owned by Adam Smith Investment Partners, L.P. and Adam
Smith Investements, Ltd.
(6) The reporting persons disclaim beneficial ownership of these securities
except to the extent of their pecuniary interest therein.
(7) These securities are owned by Adam Smith & Company, Inc., Adam Smith
Investment Partners, L.P., and Adam Smith Investments, Ltd.
/s/ Richard Grossman 2/9/00
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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.
Page 2 of 2
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Joint Filer Information
Name: Orin Hirschman
Address: 101 East 52nd Street
New York, New York 10022
Designated Filer: Richard Grossman
Issuer and Ticker Symbol: Medjet Inc. (MDJT)
Date of Event Reporting Statement: 1/31/00
Signature: /s/ Orin Hirschman
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Name: Ana Grossman
Address: 101 East 52nd Street
New York, New York 10022
Designated Filer: Richard Grossman
Issuer and Ticker Symbol: Medjet Inc. (MDJT)
Date of Event Reporting Statement: 1/31/00
Signature: /s/ Ana Grossman
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