------------------------------
OMB APPROVAL
------------------------------
OMB Number 3235-0104
Expires: December 31, 2001
Estimated average burden
hours per response ....... 0.5
------------------------------
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 or Type Responses)
- --------------------------------------------------------------------------------
1. Name and Address of Reporting Person*
Kalafa Victor
- --------------------------------------------------------------------------------
(Last) (First) (Middle)
3126 NW 60th St.
- --------------------------------------------------------------------------------
(Street)
Boca Raton Florida 33496
- --------------------------------------------------------------------------------
(City) (State) (Zip)
- --------------------------------------------------------------------------------
2. Date of Event Requiring Statement (Month/Day/Year)
2/27/02
- --------------------------------------------------------------------------------
3. IRS Identification Number of Reporting Person, if an Entity (Voluntary)
- --------------------------------------------------------------------------------
4. Issuer Name and Ticker or Trading Symbol
Cross Country, Inc. (CCRN)
- --------------------------------------------------------------------------------
5. Relationship of Reporting Person to Issuer
(Check all applicable)
[_] Director [_] 10% Owner
[x] Officer (give title below) [_] Other (specify below)
Vice President, Corporate Development
- --------------------------------------------------------------------------------
6. If Amendment, Date of Original (Month/Day/Year)
- --------------------------------------------------------------------------------
7. Individual or Joint/Group Filing (Check applicable line)
[x] Form Filed by One Reporting Person
[_] Form Filed by More than One Reporting Person
================================================================================
Table I -- Non-Derivative Securities Beneficially Owned
================================================================================
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)
- ------------------------------------------------------------------------------------------------------------------------------------
None.
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
====================================================================================================================================
* If the Form is filed by more than one Reporting Person, see Instruction
5(b)(v).
Reminder: Report on a separate line for each class of securities beneficially
owned directly or indirectly.
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)
================================================================================
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)
- ------------------------------------------------------------------------------------------------------------------------------------
Employee Stock Option (1) 7/1/2011 Common Stock 20,305 $17.00 D
(right to buy)
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
====================================================================================================================================
Explanation of Responses:
(1) The option is subject to the vesting schedule set forth in the Amended and
Restated Cross Country, Inc. Stock Option Plan. The option will be exercisable
as to 5,076 shares as of July 1, 2002, 10,153 as of July 1, 2003, 15,229 as of
July 1, 2004 and 20,305 as July 1, 2005.
VICTOR KALAFA
/s/ Victor Kalafa March 5, 2002
- --------------------------------------------- -----------------------
**Signature of Reporting Person Date
** 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.
Page 2
