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) 10/27/2004 |
3. Issuer Name and Ticker or Trading Symbol
BUILD A BEAR WORKSHOP INC [ BBW ] |
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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 | 274,815 | D |
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 | ||||
Series C-1 Convertible Preferred Stock | (1) | (1) | Common Stock | 3,418,306 | (8) | I | Smart Stuff, Inc.(2) |
Series A-5 Convertible Preferred Stock | (1) | (1) | Common Stock | 223,131 | (9) | I | Clark/Fox, L.L.C.(3) |
Seris B-4 Convertible Preferred Stock | (1) | (1) | Common Stock | 258,686 | (8) | I | Clark/Fox, L.L.C.(3) |
Seris D-1 Convertible Preferred Stock | (1) | (1) | Common Stock | 78,694 | (10) | I | Clark/Fox, L.L.C.(3) |
Series D-2 Convertible Preferred Stock | (1) | (1) | Common Stock | 91,335 | (11) | I | Clark/Fox, L.L.C.(3) |
Series D-1 Convertible Preferred Stock | (1) | (1) | Common Stock | 177,061 | (10) | I | Clark/Fox II, L.L.C.(4) |
Series D-2 Convertible Preferred Stock | (1) | (1) | Common Stock | 493,334 | (11) | I | Clark/Fox II, L.L.C.(4) |
Series D-3 Convertible Preferred Stock | (1) | (1) | Common Stock | 130,918 | (12) | I | Clark/Fox III, L.L.C.(5) |
Employee Stock Option (right to buy) | 04/24/2004(6) | 04/24/2008 | Common Stock | 36,234 | $9.1 | D | |
Employee Stock Option (right to buy) | 03/16/2005(6) | 04/01/2014 | Common Stock | 36,234 | $8.78 | D | |
Employee Stock Option (right to buy) | (13) | 04/03/2005 | Common Stock | 274,815 | $4.5 | D | |
Employee Stock Option (right to buy) | (14) | 09/13/2006 | Common Stock | 30,000 | $6.1 | D | |
Employee Stock Option (right to buy) | (7) | 09/13/2011 | Common Stock | 45,000 | $6.1 | D |
1. Name and Address of Reporting Person*
(Street)
Relationship of Reporting Person(s) to Issuer
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1. Name and Address of Reporting Person*
(Street)
Relationship of Reporting Person(s) to Issuer
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1. Name and Address of Reporting Person*
(Street)
Relationship of Reporting Person(s) to Issuer
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1. Name and Address of Reporting Person*
(Street)
Relationship of Reporting Person(s) to Issuer
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1. Name and Address of Reporting Person*
(Street)
Relationship of Reporting Person(s) to Issuer
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Explanation of Responses: |
1. Convertible upon demand. All shares of preferred stock will convert automatically upon consummation of the Company's initial public offering. |
2. Maxine Clark is the President and Sole Shareholder of Smart Stuff, Inc. |
3. Maxine Clark is the Manager of Clark/Fox, L.L.C. Maxine Clark disclaims beneficial ownership of the shares owned by Clark/Fox, L.L.C. except to the extent of her pecuniary interest therein, which consists of 69,498 shares. |
4. Maxine Clark is the Manager of Clark/Fox II, L.L.C. Maxine Clark disclaims beneficial ownership of the shares owned by Clark/Fox II, L.L.C. except to the extent of her pecuniary interest therein, which consists of 57,372 shares. |
5. Maxine Clark is the Manager of Clark/Fox III, L.L.C. Maxine Clark disclaims beneficial ownership of the shares owned by Clark/Fox III, L.L.C. except to the extent of her pecuniary interest therein, which consists of 18 shares. |
6. The options vest 25% each year beginning on the date specified. All options will automatically vest upon the consummation of the Company's initial public offering. |
7. The options with respect to 15,000 shares vest on each of September 13, 2002, 2003 and 2004. |
8. 1-to-1 |
9. 1.303334-to-1 |
10. 1.200083-to-1 |
11. 1.188825-to-1 |
12. 1.183108-to-1 |
13. The options vest with respect to 54,963 shares on April 3, 2002, and 109,926 shares on each of April 3, 2003 and 2004. |
14. The options vest with respect to 15,000 shares on each of September 13, 2001 and 2005. |
/s/ John Burtelow, Attorney-in-fact for Maxine Clark | 10/27/2004 | |
** 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. |