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 |
|
1. Name and Address of Reporting Person*
(Street)
|
2. Date of Event Requiring Statement
(Month/Day/Year) 09/01/2011 |
3. Issuer Name and Ticker or Trading Symbol
Alliance HealthCare Services, Inc [ AIQ ] |
|||||||||||||
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
|
5. If Amendment, Date of Original Filed
(Month/Day/Year) |
||||||||||||||
6. Individual or Joint/Group Filing (Check Applicable Line)
|
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 | 34,275 | D | |
Common Stock | 50,000(1) | D |
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 | 02/03/2011(2) | 02/03/2016 | Common Stock | 35,000 | $4.19 | D | |
Employee Stock Option | 01/03/2010(3) | 01/03/2015 | Common Stock | 8,000 | $12.35 | D | |
Employee Stock Option | 01/05/2009(4) | 01/05/2014 | Common Stock | 7,500 | $3.67 | D | |
Employee Stock Option | 01/15/2008(5) | 01/15/2013 | Common Stock | 5,000 | $5.19 | D |
Explanation of Responses: |
1. The shares shall vest in their entirety and all restrictions with reespect thereto shall lapse on December 31, 2011 |
2. Options became exercisable with respect to five percent (5%) on the first aniversary of February 3, 2006 ("Vesting Reference Date"); Twenty Percent (20%) on the second anniversary date of the Vesting Reference Date and Twenty-Five percent (25%) on each of the third through fifth anniversaries of the Vesting Reference Date. |
3. Options became exercisable with respect to five percent (5%) on the first aniversary of January 3, 2005 ("Vesting Reference Date"); Twenty Percent (20%) on the second anniversary date of the Vesting Reference Date and Twenty-Five percent (25%) on each of the third through fifth anniversaries of the Vesting Reference Date. |
4. Options became exercisable with respect to five percent (5%) on the first aniversary of January 5, 2004 ("Vesting Reference Date"); Twenty Percent (20%) on the second anniversary date of the Vesting Reference Date and Twenty-Five percent (25%) on each of the third through fifth anniversaries of the Vesting Reference Date. |
5. Options became exercisable with respect to five percent (5%) on the first aniversary of January 15, 2003 ("Vesting Reference Date"); Twenty Percent (20%) on the second anniversary date of the Vesting Reference Date and Twenty-Five percent (25%) on each of the third through fifth anniversaries of the Vesting Reference Date. |
Leigh Ann Clifford, with Power of Attorney | 09/09/2011 | |
** 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. |