SEC FORM
3
SEC Form 3
| FORM 3 |
UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES
Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934
or Section 30(h) of the Investment Company Act of 1940
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| OMB APPROVAL |
| OMB Number: |
3235-0104 |
| Estimated average burden |
| hours per response: |
0.5 |
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1. Name and Address of Reporting Person*
| C/O LEMAITRE VASCULAR, INC. |
| 63 SECOND AVENUE |
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year)
04/28/2020
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3. Issuer Name and Ticker or Trading Symbol
LEMAITRE VASCULAR INC
[ LMAT ]
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
| X |
Director |
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10% Owner |
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Officer (give title below) |
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Other (specify below) |
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5. If Amendment, Date of Original Filed
(Month/Day/Year)
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6. Individual or Joint/Group Filing (Check Applicable Line)
| X |
Form filed by One Reporting Person |
|
Form filed by More than One Reporting Person |
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| Table I - Non-Derivative Securities Beneficially Owned |
|---|
| 1. Title of Security (Instr.
4)
|
2.
Amount of Securities Beneficially Owned (Instr.
4)
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3. Ownership Form: Direct (D) or Indirect (I) (Instr.
5)
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4. Nature of Indirect Beneficial Ownership (Instr.
5)
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Table II - Derivative Securities Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
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|---|
| 1. Title of Derivative Security (Instr.
4)
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2. Date Exercisable and Expiration Date
(Month/Day/Year) |
3. Title and Amount of Securities Underlying Derivative Security (Instr.
4)
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4. Conversion or Exercise Price of Derivative Security
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5. Ownership Form: Direct (D) or Indirect (I) (Instr.
5)
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6. Nature of Indirect Beneficial Ownership (Instr.
5)
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| Date Exercisable |
Expiration Date |
Title |
Amount or Number of Shares |
| Explanation of Responses: |
| Remarks: |
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| No securities are beneficially owned. |
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/s/ Laurie A. Churchill, Attorney-in-fact |
05/08/2020 |
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** Signature of Reporting Person |
Date |
| Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. |
| * If the form is filed by more than one reporting person,
see
Instruction
5
(b)(v). |
| ** 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 is insufficient,
see
Instruction 6 for procedure. |
| Persons who respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB Number. |
EXHIBIT 24.1
POWER OF ATTORNEY
KNOW ALL MEN BY THESE PRESENTS, that the person whose signature appears
below hereby constitutes and appoints each of Laurie A. Churchill and
Nicole C. Brookshire, signing singly and each acting individually,
as the undersigned's true and lawful attorney-in-fact and agent, with
full power of substitution and resubstitution, for the undersigned and
in the undersigned's name, place, and stead, in any and all capacities
to sign any and all instruments, certificates, and documents approved
by the undersigned that, as a result of the undersigned's service as
an executive officer or director of LeMaitre Vascular, Inc.
(the "Company"), are required to be executed on behalf of the
undersigned pursuant to Sections 13 and 16 of the Securities Exchange
Act of 1934, as amended (the "Exchange Act"), and any and all
regulations promulgated thereunder, and to file the same, with all
exhibits thereto, and any other documents in connection therewith, with
the Securities and Exchange Commission, and with any other entity when
and if such is mandated by the Exchange Act, granting unto said
attorney-in-fact and agent full power and authority to do and perform
each and every act and thing requisite and necessary fully to all intents
and purposes as the undersigned might or could do in person thereby
ratifying and confirming all that said attorney-in-fact and agent, or
her substitute or substitutes, may lawfully do or cause to be done by
virtue hereof.
The undersigned acknowledges that this Power of Attorney
authorizes, but does not require, each such attorney-in-fact to act in
their discretion on information provided to such attorney-in-fact without
independent verification of such information; any documents prepared
and/or executed by any such attorney-in-fact on behalf of the undersigned
pursuant to this Power of Attorney will be in such form and will contain
such information and disclosure as such attorney-in-fact, in her
discretion, deems necessary or desirable; neither the Company nor any
such attorneys-in-fact assumes (i) any liability for the undersigned's
responsibility to comply with the requirement of the Exchange Act,
(ii) any liability of the undersigned for any failure to comply with
such requirements, or (iii) any obligation or liability of the undersigned
for profit disgorgement under Section 16(b) of the Exchange Act; and this
Power of Attorney does not relieve the undersigned from responsibility
for compliance with the undersigned's obligations under the Exchange Act,
including without limitation the reporting requirements under Section 16
of the Exchange Act.
This Power of Attorney shall remain in effect until it is revoked in
writing or the undersigned has ceased to serve as an executive officer
or director of LeMaitre Vascular, Inc.
IN WITNESS WHEREOF, this Power of Attorney has been signed as of May 5, 2020.
/s/ Bridget A. Ross
Print Name: Bridget A. Ross
