SEC FORM
4
SEC Form 4
| FORM 4 |
UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP
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 Number: |
3235-0287 |
| Estimated average burden |
| hours per response: |
0.5 |
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Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue.
See
Instruction 1(b). |
1. Name and Address of Reporting Person*
| C/O ICU MEDICAL INC |
| 951 CALLE AMANECER |
(Street)
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2. Issuer Name and Ticker or Trading Symbol
ICU MEDICAL INC/DE
[ icui ]
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5. 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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3. Date of Earliest Transaction
(Month/Day/Year)
08/16/2003
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4. 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 |
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Form filed by More than One Reporting Person |
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| Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned |
|---|
| 1. Title of Security (Instr.
3)
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2. Transaction Date
(Month/Day/Year) |
2A. Deemed Execution Date, if any
(Month/Day/Year) |
3. Transaction Code (Instr.
8)
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4. Securities Acquired (A) or Disposed Of (D) (Instr.
3, 4 and 5)
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5.
Amount of Securities Beneficially Owned Following Reported Transaction(s) (Instr.
3 and 4)
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6. Ownership Form: Direct (D) or Indirect (I) (Instr.
4)
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7. Nature of Indirect Beneficial Ownership (Instr.
4)
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| Code |
V |
Amount |
(A) or (D) |
Price |
Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
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|---|
| 1. Title of Derivative Security (Instr.
3)
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2. Conversion or Exercise Price of Derivative Security
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3. Transaction Date
(Month/Day/Year) |
3A. Deemed Execution Date, if any
(Month/Day/Year) |
4. Transaction Code (Instr.
8)
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5.
Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr.
3, 4 and 5)
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6. Date Exercisable and Expiration Date
(Month/Day/Year) |
7. Title and Amount of Securities Underlying Derivative Security (Instr.
3 and 4)
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8. Price of Derivative Security (Instr.
5)
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9.
Number of derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr.
4)
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10. Ownership Form: Direct (D) or Indirect (I) (Instr.
4)
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11. Nature of Indirect Beneficial Ownership (Instr.
4)
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| Code |
V |
(A) |
(D) |
Date Exercisable |
Expiration Date |
Title |
Amount or Number of Shares |
| Non-Qualified Stock Option (right to buy) |
$28.635
|
08/16/2003 |
|
A |
|
1,875 |
|
02/16/2004 |
08/16/2014 |
Common Stock |
1,875 |
|
1,875 |
D |
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| Explanation of Responses: |
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|
By: Lynn DeMartini For: Jack W. Brown |
08/18/2003 |
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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
4
(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
SEC FORMS 3, 4 and 5
The undersigned, Jack W. Brown, hereby appoints and designates each of
Lynn DeMartini and Janice Rough his attorney-in-fact, signing singly,
to execute and file on the undersigned?s behalf all Forms 3, 4,
and 5 (including any amendments thereto) that the undersigned may be
required to file with the U.S. Securities and Exchange Commission as
a result of the undersigned?s ownership of or transactions in securities
of ICU Medical, Inc. Any previous authority to act on the undersigned?s
behalf in connection with such execution and filing of Forms 3, 4 and 5
is hereby revoked and the authority of Lynn DeMartini and Janice Rough
under this Statement shall continue until the undersigned is no longer
required to file Forms 3, 4 and 5 with regard to the undersigned?s
ownership of or transactions in securities of ICU Medical, Inc.,
unless earlier revoked in writing. The undersigned acknowledges
that neither Lynn DeMartini nor Janice Rough is assuming any
of the undersigned?s responsibilities to comply with Section 16
of the Securities Exchange Act of 1934.
Date: August 15, 2003
/s/ Jack W. Brown
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Jack W. Brown
