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OMB APPROVAL
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OMB Number: 3235-0104
Expires: December 31, 2001
Estimated average burden
hours per response........0.5
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U.S. SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
FORM 3
INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES
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
(Print of Type Responses)
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1. Name and Address of Reporting Person*
Nowakowski Susan R.
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(Last) (First) (Middle)
c/o AMN Healthcare Services, Inc.
12235 El Camino Real, Suite 200
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(Street)
San Diego CA 92130
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(City) (State) (Zip)
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2. Date of Event Requiring Statement (Month/Day/Year)
11/12/2001
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3. IRS Identification Number of Reporting Person, if an Entity (Voluntary)
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4. Issuer Name and Ticker or Trading Symbol
AMN Healthcare Services, Inc. ("AHS")
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5. Relationship of Reporting Person to Issuer
(Check all applicable)
[_] Director [_] 10% Owner
[X] Officer (give title below) [_] Other (specify below)
CHIEF OPERATING OFFICER AND SECRETARY
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6. If Amendment, Date of Original (Month/Day/Year)
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7. 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
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3. Ownership Form:
2. Amount of Securities Direct (D) or
1. Title of Security Beneficially Owned Indirect (I) 4. Nature of Indirect Beneficial Ownership
(Instr. 4) (Instr. 4) (Instr. 5) (Instr. 4)
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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).
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.
(Over)
SEC 1473(3-99)
FORM 3 (continued)
TABLE II -- DERIVATIVE SECURITIES BENEFICIALLY OWNED
(E.G., PUTS, CALLS, WARRANTS, OPTIONS, CONVERTIBLE SECURITIES)
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5. Owner-
3. Title and Amount of Securities ship
Underlying Derivative Security Form of
2. Date Exercisable (Instr. 4) Derivative
and Expiration Date --------------------------------- 4. Conver- Security:
(Month/Day/Year) Amount sion or Direct 6. Nature of
---------------------- or Exercise (D) or Indirect
Date Expira- Number Price of Indirect Beneficial
1. Title of Derivative Exer- tion of Derivative (I) Ownership
Security (Instr. 4) cisable Date Title Shares Security (Instr. 5) (Instr. 5)
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Employee Stock Option (1) 11/19/2009 Common Stock, par 339,350 $3.80 D
(right to buy) value $0.01 per share
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Employee Stock Option (2) 12/31/2009 Common Stock, par 202,006 $3.80 D
(right to buy) value $0.01 per share
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Employee Stock Option (3) 12/31/2009 Common Stock, par 119,445 $6.68 D
(right to buy) value $0.01 per share
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Explanation of Responses:
(1) Options to purchase 84,837.5 shares become exercisable on December 31,
2001, options to purchase 84,837.5 shares become exercisable on May 14, 2001,
options to purchase 84,837.5 shares become exercisable on December 31, 2002 and
options to purchase 84,837.5 shares become exercisable on December 31, 2003.
(2) Options to purchase 50,501.5 shares become exercisable on December 31,
2001, options to purchase 50,501.5 shares become exercisable on May 14, 2001,
options to purchase 50,501.5 shares become exercisable on December 31, 2002 and
options to purchase 50,501.5 shares become exercisable on December 31, 2003.
(3) Options to purchase 29,861.25 shares become exercisable on May 14, 2001,
options to purchase 29,861.25 shares become exercisable on December 31, 2002,
options to purchase 29,861.25 shares become exercisable on December 31, 2003 and
option to purchae 29,861.25 shares become exercisable on December 31, 2004.
/s/ Susan R. Nowakowski November 13, 2001
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**Signature of Reporting Person Date
Name: Susan R. Nowakowski
** 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.
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.
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