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 GOLDMAN, SACHS & CO. |
| 200 WEST STREET |
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year)
09/01/2010
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3. Issuer Name and Ticker or Trading Symbol
AMN HEALTHCARE SERVICES INC
[ AHS ]
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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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| Common Stock |
28,184 |
I |
See footnotes
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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: |
|
|
|
/s/ Yvette Kosic, Attorney-in-fact |
09/03/2010 |
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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. |
POWER OF ATTORNEY
The undersigned does hereby appoint Bruce A. Albert, Anthony
DeRose, Yvette Kosic, Rachel Parrish and Kevin P. Treanor,(and any other
employee of The Goldman Sachs Group, Inc. or one of its affiliates
designated in writing by one of the attorneys-in-fact), his true and lawful
attorneys, and each one of them his true and lawful attorney, with power to
act without the other, and with full power of substitution and resubstitution,
to execute for his and in his name any and all filings required to be made by
him under the Securities Exchange Act of 1934 (as amended, the "Act"), with
respect to securities which may be deemed to be beneficially owned by him
under the Act, and any and all instruments necessary or incidental therewith,
hereby granting unto said attorneys and each of them full power and authority
to do and perform in the name and on behalf of the undersigned, and in any
and all capacities, every act and thing whatsoever required or necessary
to be done in and about the premises, as fully and to all intents and
purposes as the undersigned might or could do in person, hereby ratifying
and approving the act of said attorneys and each of them.
This Power of Attorney shall not be affected by the subsequent
disability or incompetence of the principal. This Power of Attorney shall
remain in full force and effect until either revoked in writing by the
undersigned or until such time as the person or persons to whom power of
attorney has been hereby granted cease(s) to be an employee of The Goldman
Sachs Group, Inc. or one of its affiliates. This Power of Attorney does not
revoke any existing Powers of Attorney executed by the undersigned.
This Power of Attorney recites the text provided in Section 5-1513 of the
General Obligations Law of the State of New York in the form attached hereto
as Annex 1 (the "Cautionary Language"). For the avoidance of doubt, the
undersigned understands and agrees, and affirms that it is his intent, that
if any provision contained in the Cautionary Language shall be inconsistent
with any provision contained in this Limited Power of Attorney, the provision
contained in this Limited Power of Attorney shall prevail to the fullest
extent permitted by law. Nothing in this Limited Power of Attorney shall
be construed as an admission or acknowledgment of the undersigned that this
Limited Power of Attorney is subject to the requirements of Section 5-1501B
of the General Obligations Law of the State of New York.
In witness thereof the undersigned hereunto signed his name this
17th day of August, 2010.
/s/ Martin Chavez
Martin Chavez
STATE OF: New York
COUNTY OF: New York
On the 17th day of August, 2010 before me personally came
to me known and known to me to be the individual described in, and who
executed the foregoing instrument, and such individual acknowledged to me
that he executed the same.
/s/ Laura Barnao
Notary Public
My term expires: 5/12/11
ACKNOWLEDGMENT OF APPOINTMENT OF ATTORNEYS-IN-FACT
Dated: August 19, 2010
/s/ Bruce A. Albert
Bruce A. Albert, Attorney-in-fact
/s/ Anthony DeRose
Anthony DeRose, Attorney-in-fact
/s/ Yvette Kosic
Yvette Kosic, Attorney-in-fact
/s/ Rachel Parrish
Rachel Parrish, Attorney-in-fact
/s/ Kevin P. Treanor
Kevin P. Treanor, Attorney-in-fact
STATE OF: New Jersey
On the 19th day of August, 2010 before me personally came
to me known and known to me to be the individuals described in, and who
executed the foregoing instrument, and such individuals acknowledged to
me that they executed the same.
/s/ Bridget Donovan
Notary Public
My term expires: 11-20-2014
ANNEX 1
CAUTIONARY LANGUAGE
CAUTION TO THE PRINCIPAL:
Your Power of Attorney is an important document. As the "principal,"
you give the person whom you choose (your "agent") authority to spend your
money and sell or dispose of your property during your lifetime without
telling you. You do not lose your authority to act even though you have given
your agent similar authority.
When your agent exercises this authority, he or she must act
according to any instructions you have provided or, where there are no
specific instructions, in your best interest. "Important Information for
the Agent" at the end of this document describes your agent's
responsibilities.
Your agent can act on your behalf only after signing the Power of
Attorney before a notary public.
You can request information from your agent at any time. If you are
revoking a prior Power of Attorney by executing this Power of Attorney, you
should provide written notice of the revocation to your prior agent(s) and
to the financial institutions where your accounts are located.
You can revoke or terminate your Power of Attorney at any time for any reason
as long as you are of sound mind. If you are no longer of sound mind, a court
can remove an agent for acting improperly.
Your agent cannot make health care decisions for you. You may execute a
"Health Care Proxy" to do this.
The law governing Powers of Attorney is contained in the New York
General Obligations Law, Article 5, Title 15. This law is available at a
law library, or online through the New York State Senate or Assembly
websites, www.senate.state.ny.us or www.assembly.state.ny.us.
If there is anything about this document that you do not understand,
you should ask a lawyer of your own choosing to explain it to you.
IMPORTANT INFORMATION FOR THE AGENT:
When you accept the authority granted under this Power of Attorney,
a special legal relationship is created between you and the principal.
This relationship imposes on you legal responsibilities that continue
until you resign or the Power of Attorney is terminated or revoked.
You must:
(1) act according to any instructions from the principal, or, where there are
no instructions, in the principal's best interest;
(2) avoid conflicts that would impair your ability to act in the
principal's best interest;
(3) keep the principal's property separate and distinct from any assets
you own or control, unless otherwise permitted by law;
(4) keep a record or all receipts, payments, and transactions conducted for
the principal; and
(5) disclose your identity as an agent whenever you act for the principal
by writing or printing the principal's name and signing your own name as
"agent" in either of the following manner: (Principal's Name) by (Your
Signature) as Agent, or (your signature) as Agent for (Principal's Name).
You may not use the principal's assets to benefit yourself or
give major gifts to yourself or anyone else unless the principal has
specifically granted you that authority in this Power of Attorney or in a
Statutory Major Gifts Rider attached to this Power of Attorney. If you have
that authority, you must act according to any instructions of the principal
or, where there are no such instructions, in the principal's best interest.
You may resign by giving written notice to the principal and to any
co-agent, successor agent, monitor if one has been named in this document,
or the principal's guardian if one has been appointed. If there is anything
about this document or your responsibilities that you do not understand,
you should seek legal advice.
Liability of agent:
The meaning of the authority given to you is defined in New York's General
Obligations Law, Article 5, Title 15. If it is found that you have violated
the law or acted outside the authority granted to you in the Power of
Attorney, you may be liable under the law for your violation.
