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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1. Name and Address of Reporting Person*
Polipnick Gary A.

(Last) (First) (Middle)
2413 ADVANCE ROAD

(Street)
MADISON WI 53718

(City) (State) (Zip)
2. Date of Event Requiring Statement (Month/Day/Year)
07/23/2012
3. Issuer Name and Ticker or Trading Symbol
FASTENAL CO [ FAST ]
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
Director 10% Owner
X Officer (give title below) Other (specify below)
Executive Vice President
5. If Amendment, Date of Original Filed (Month/Day/Year)
6. 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
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 54,072 (1) D
Common Stock 1,728 (2) D
Common Stock 895 (2) (3) I Held by Spouse
Common Stock 2,468 (3) I Held by Daughter
Common Stock 1,789 (3) I Held in custodian account for Daughter
Common Stock 893 (3) I Held in custodian account for Daughter
Common Stock 2,661 (3) I By Trust (4)
Common Stock 3,033 (7) I Held in 401(K) Plan
Table II - Derivative Securities Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
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
Employee Stock Option (Right to Buy) (5) 05/31/2016 Common Stock 10,000 22.5 D
Employee Stock Option (Right to Buy) (5) 05/31/2018 Common Stock 30,000 27 D
Employee Stock Option (Right to Buy) (6) 05/31/2021 Common Stock 2,500 54 D
Explanation of Responses:
1. Shares held jointly by reporting person and his spouse.
2. Shares maintained in a self-directed IRA.
3. Reporting person disclaims beneficial ownership of these shares.
4. Reporting person's spouse serves as a Trustee of a Trust maintained for the benefit of spouse's sibling.
5. This option will vest and become exercisable over a period of eight years, with 50% of the option vesting and becoming exercisable half way through the relevant vesting period and the remainder vesting and becoming exercisable proportionately on each anniversary of the date of grant of the option occuring after the initial 50% vesting date.
6. This option will vest and become exercisable over a period of five years, with 50% of the option vesting and becoming exercisable half way through the relevant vesting period and the remainder vesting and becoming exercisable incrementally (20%,20% and 10% respectively) on each anniversary of the date of grant of the option occuring after the initial 50% vesting date.
7. Shares attributed to reporting person's account within issuer's 401(K) Plan as of June 30, 2012.
/s/ John J. Milek, Attorney-in-Fact 07/30/2012
** 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.