0001144204-11-071319.txt : 20111222 0001144204-11-071319.hdr.sgml : 20111222 20111222212925 ACCESSION NUMBER: 0001144204-11-071319 CONFORMED SUBMISSION TYPE: 4/A PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20111216 FILED AS OF DATE: 20111222 DATE AS OF CHANGE: 20111222 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Burgon Paul CENTRAL INDEX KEY: 0001480555 FILING VALUES: FORM TYPE: 4/A SEC ACT: 1934 Act SEC FILE NUMBER: 000-53769 FILM NUMBER: 111278856 MAIL ADDRESS: STREET 1: 5314 N. RIVER RUN DRIVE, SUITE 350 CITY: PROVO STATE: UT ZIP: 84604 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: LIQTECH INTERNATIONAL INC CENTRAL INDEX KEY: 0001307579 STANDARD INDUSTRIAL CLASSIFICATION: MISC INDUSTRIAL & COMMERCIAL MACHINERY & EQUIPMENT [3590] IRS NUMBER: 201431677 STATE OF INCORPORATION: NV FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: INDUSTRIPARKEN 22C CITY: BALLERUP STATE: G7 ZIP: DK-2750 BUSINESS PHONE: 01145 2390 4545 MAIL ADDRESS: STREET 1: INDUSTRIPARKEN 22C CITY: BALLERUP STATE: G7 ZIP: DK-2750 FORMER COMPANY: FORMER CONFORMED NAME: Blue Moose Media Inc DATE OF NAME CHANGE: 20041101 4/A 1 form4a.xml OWNERSHIP DOCUMENT X0304 4/A 2011-12-16 2011-12-20 0 0001307579 LIQTECH INTERNATIONAL INC LIQT 0001480555 Burgon Paul 5314 N. RIVER RUN DRIVE, SUITE 350 PROVO UT 84604 1 0 0 0 Stock options 3.60 2011-12-16 4 A 0 20000 0 A 2014-12-16 Common stock 20000 20000 D The options vest in three equal annual installments on December 16, 2011, September 1, 2012 and September 1, 2013. /s/ Paul Burgon 2011-12-22