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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1. Name and Address of Reporting Person*
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year) 05/05/2011 |
3. Issuer Name and Ticker or Trading Symbol
EnteroMedics Inc [ ETRM ] |
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
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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)
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Table I - Non-Derivative Securities Beneficially Owned | |||
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1. Title of Security (Instr. 4) | 2. Amount of Securities Beneficially Owned (Instr. 4) | 3. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) | 4. Nature of Indirect Beneficial Ownership (Instr. 5) |
Common Stock | 25,000 | I | Family Trust(1) |
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) | 2. Date Exercisable and Expiration Date (Month/Day/Year) | 3. Title and Amount of Securities Underlying Derivative Security (Instr. 4) | 4. Conversion or Exercise Price of Derivative Security | 5. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) | 6. Nature of Indirect Beneficial Ownership (Instr. 5) | ||
Date Exercisable | Expiration Date | Title | Amount or Number of Shares |
Explanation of Responses: |
1. The reporting person disclaims beneficial interest in the shares held by the Trust. |
Remarks: |
EXHBIT 24: Power of Attorney attached. |
/s/ Mark B. Knudson, Attorney-in-Fact for Anthony P. Jansz | 05/09/2011 | |
** 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. |
POWER OF ATTORNEYKnow all by these presents, that I hereby constitute and appoint each of Mark B. Knudson and
Greg S. Lea my true and lawful attorney-in-fact and agent, each acting along, with full power of
substitution for me and in my name, place and stead, to:1. execute for me and on my behalf, in my capacity as an officer and/or director of EnteroMedics Inc,
Forms 3, 4 or 5 in accordance with Section 16(a) of the Securities Exchange Act of 1934, as amended,
and the rules promulgated thereunder;2. do and perform any and all acts for me and on my behalf which may be necessary or desirable to
complete and execute any such Form 3, 4 or 5, complete and execute any amendment or amendments thereto
and timely file such Form with the United States Securities and Exchange Commission and any stock exchange
or similar authority; and3. take any other action of any type whatsoever in connection with the foregoing which, in the opinion
of such attorney-in-fact, may be of benefit to me, in my best interest or legally required by me, it being
understood that the documents executed by such attorney-in-fact on my behalf pursuant to this Power of
Attorney shall be in such form and shall contain such terms and conditions as such attorney-in-fact may
approve in such attorney-in-fact's discretion.I hereby grant to each such attorney-in-fact full power and authority to do and perform any 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 I might or could do if personally
present, hereby ratifying and confirming all that such attorney-in-fact, or such attorney-in-fact's
substitute or substitutes, shall lawfully do or cause to be done by virtue of this Power of Attorney and
the rights and powers herein granted. I acknowledge that the attorneys-in-fact, in serving in such capacity
at my request, are not assuming, nor is EnteroMedics Inc. assuming, any of my responsibilities to comply
with Section 16 of the Securities Exchange Act of 1934, as amended.This Power of Attorney shall remain in full force and effect until I am no longer required to file
Forms 3, 4 and 5 with respect to my holdings of and transactions in securities of EnteroMedics Inc, unless
earlier revoked by me in a signed writing delivered to the attorneys-in-fact named above.IN WITNESS WHEREOF, I have signed this Power of Attorney on May 5, 2011.
/s/ Anthony P. JanszAnthony P. Jansz