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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 or Type Responses)
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1. Name and Address of Reporting Person*
Lewis Daniel J.
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(Last) (First) (Middle)
1108 S.E. 14th Ave.
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(Street)
Deerfield Park FL 33441
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(City) (State) (Zip)
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2. Date of Event Requiring Statement (Month/Day/Year)
As of 10/24/01
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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
Cross Country, Inc. (CCRN)
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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)
Controller
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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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Common Stock 8,065 D
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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) 12/16/09 Common Stock 32,052 (2) D
(right to buy)
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Employee Stock Option
(right to buy) (3) 12/16/09 Common Stock 7,542 $7.75 D
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Explanation of Responses:
(1) The option is subject to the vesting schedule set forth in the Cross
Country, Inc. Amended and Restated Equity Participation Plan. 16,026 shares are
immediately exercisable. The option will be exercisable as to 20,033 shares as
of June 16, 2002, 24,039 shares as of December 16, 2002, 28,046 shares as of
June 16, 2003, and 32,052 shares as of December 16, 2003.
(2) Pursuant to the Cross Country, Inc. Amended and Restated Equity
Participation Plan, the first tranche of 5,736 shares will be exercisable at
$7.75 per share, the second tranche of 10,796 shares will be exercisable at
$11.62 per share, the third tranche of 10,796 shares will be exercisable at
$15.50 per share, the fourth tranche of 2,362 shares will be exercisable at
$19.37 per share and the remaining tranche of 2,362 shares will be exercisable
at $23.25 per share.
(3) The option is subject to the vesting schedule set forth in the Cross
Country, Inc. Amended and Restated 1999 Stock Option Plan. The option is
immediately exercisable as to 3,771 shares. The option will be exercisable as to
5,657 shares as of December 16, 2002, 7,542 as of December 16, 2003.
Daniel J. Lewis
/s/ Daniel J. Lewis 5/7/02
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**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 Page 2
unless the form displays a currently
valid OMB Number.
