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 AQUABOUNTY TECHNOLOGIES, INC. |
| TWO MILL AND MAIN PLACE, SUITE 395 |
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year)
12/30/2016
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3. Issuer Name and Ticker or Trading Symbol
AquaBounty Technologies, Inc.
[ AQB ]
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
|
Director |
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10% Owner |
| X |
Officer (give title below) |
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Other (specify below) |
| See Remarks |
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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 |
| Options to Purchase Common Stock |
06/01/2018
|
06/01/2025 |
Common Stock |
100,000 |
0.23 |
D |
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| Explanation of Responses: |
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| Remarks: |
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/s/ David A. Frank, Name: David A. Frank, attorney-in-fact |
12/30/2016 |
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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. |
AQUABOUNTY TECHNOLOGIES, INC.
POWER OF ATTORNEY - SEC Forms 3, 4 and 5 Filings
The undersigned hereby constitutes and appoints David A. Frank, Chief
Financial Officer and Treasurer of AquaBounty Technologies, Inc. (the
"Company"), with full power of substitution, as the undersigned's true and
lawful authorized representative and attorney-in-fact to:
(1) execute for and on behalf of the undersigned, in the
undersigned's capacity as an officer or director of the Company,
Forms 3, 4, and 5, and any and all amendments thereto, in
accordance with Section 16 of the Securities and Exchange Act of
1934, as amended (the "1934 Act"), and the rules and regulations
promulgated thereunder;
(2) do and perform any and all acts for and on behalf of the
undersigned that may be necessary or desirable to complete the
execution of any such form or schedule and the timely filing of
such form or schedule with the United States Securities and
Exchange Commission and any stock exchange or stock market or
other authority; and
(3) take any other action of any type whatsoever in connection with
the foregoing that, in the opinion of such attorney-in-fact, may
be of benefit to, in the best interest of, or legally required
by, the undersigned, it being understood that the documents
executed by such attorney-in-fact on behalf of the undersigned
pursuant to this Power of Attorney will be in such form and will
contain such terms and conditions as such attorney-in-fact may
approve in such attorney-in-fact's discretion.
The undersigned hereby grants to such attorney-in-fact full power and
authority to do and perform all and every act and thing whatsoever requisite,
necessary or proper to be done in the exercise of any of the rights and powers
herein granted, as fully to all intents and purposes as the undersigned might or
could do if personally present, with full power of substitution or revocation,
hereby ratifying and confirming all that such attorney-in-fact, or such
attorney-in-fact's substitute, will lawfully do or cause to be done by virtue of
this power of attorney and the rights and powers herein granted. The undersigned
acknowledges that each foregoing attorney-in-fact, in service in such capacity
at the request of the undersigned, is not assuming, nor is the Company assuming,
any of the undersigned's responsibilities to comply with Section 16 or any other
provision of the 1934 Act. Notwithstanding the filing of these reports on your
behalf by the Company, the undersigned will remain responsible for the accuracy
of all information provided to the Company in connection with the filing of such
reports.
This Power of Attorney will remain in full force and effect until the
undersigned is no longer required to file Forms 3, 4 and 5 with respect to the
undersigned's holding of or transactions in securities issued by Company, unless
earlier revoked by the undersigned in a signed writing delivered to the
foregoing attorneys-in-fact.
Signed: /s/ Christopher Martin
----------------------
Print Name: Christopher Martin
Dated: December 27, 2016
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[Signature page to Power of Attorney - SEC Forms 3,4 and 5 Filings]
