SEC FORM
3
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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| OMB APPROVAL |
| OMB Number: |
3235-0104 |
| Estimated average burden |
| hours per response: |
0.5 |
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1. Name and Address of Reporting Person*
| C/O CREATIVE REALITIES, INC. |
| 22 AUDREY PLACE |
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year)
11/06/2015
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3. Issuer Name and Ticker or Trading Symbol
CREATIVE REALITIES, INC.
[ CREX ]
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
| X |
Director |
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10% Owner |
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Officer (give title below) |
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Other (specify below) |
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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)
| X |
Form filed by One Reporting Person |
|
Form filed by More than One Reporting Person |
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| Table I - Non-Derivative Securities Beneficially Owned |
|---|
| 1. Title of Security (Instr.
4)
|
2.
Amount of Securities Beneficially Owned (Instr.
4)
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3. Ownership Form: Direct (D) or Indirect (I) (Instr.
5)
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4. Nature of Indirect Beneficial Ownership (Instr.
5)
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| Common Stock |
0 |
D |
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Table II - Derivative Securities Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
|
|---|
| 1. Title of Derivative Security (Instr.
4)
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2. Date Exercisable and Expiration Date
(Month/Day/Year) |
3. Title and Amount of Securities Underlying Derivative Security (Instr.
4)
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4. Conversion or Exercise Price of Derivative Security
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5. Ownership Form: Direct (D) or Indirect (I) (Instr.
5)
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6. Nature of Indirect Beneficial Ownership (Instr.
5)
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| Date Exercisable |
Expiration Date |
Title |
Amount or Number of Shares |
| Explanation of Responses: |
| Remarks: |
|
|
/s/ John Waluck at Attorney-in-Fact for Patrick O'Brien |
10/20/2016 |
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** 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 ATTORNEY
For Executing Forms 3, 4 and 5
Know all by these presents, that the undersigned hereby
constitutes and appoints John J. Walpuck, III and Paul D.
Chestovich, signing individually, his true and lawful
attorneys-in-fact to:
1. Execute for and on behalf of the undersigned Initial
Statements of Beneficial Ownership of Securities on Form 3,
Statements of Changes of Beneficial Ownership of Securities
on Form 4 and Annual Statements of Beneficial Ownership of
Securities on Form 5, for the purpose of reporting
transactions by the undersigned in securities issued by
Creative Realities, Inc. in accordance with Section 16(a) of
the Securities Exchange Act of 1934 and the rules
thereunder;
2. Do and perform any and all acts for and on behalf of
the undersigned which may be necessary or desirable to
complete the execution of any such Form 3, 4 or 5 and the
timely filing thereof with the United States Securities and
Exchange Commission and any other applicable governmental or
regulatory authority; and
3. 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, in the best interest
of, or legally required by, the undersigned, it being
understood that the documents executed by such attorney-in-
fact on behalf of the undersigned 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 his
discretion.
The undersigned hereby grants to each such attorney-in-fact
full power and authority to do and perform all and every act
and thing whatsoever requisite, necessary and proper to be
done in the exercise of any of the rights and powers herein
granted, as fully to all intents and purposes as such
attorney-in-fact might or could do if personally present,
with full power of substitution or revocation, hereby
ratifying and confirming all that such attorney-in-fact, or
his 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. The undersigned acknowledges that
the foregoing attorneys-in-fact, in serving in such capacity
at the request of the undersigned, are not assuming any of
the undersigned's responsibilities to comply with Section 16
of the Securities Exchange Act of 1934.
This Power of Attorney shall remain in full force and effect
until the undersigned is no longer required to file Forms 3,
4 and 5 with respect to the undersigned's holdings of and
transactions in securities issued by Creative Realities,
Inc., unless earlier revoked by the undersigned in a signed
writing delivered to the foregoing attorneys-in-fact.
IN WITNESS WHEREOF, the undersigned has executed this Power
of Attorney as of this 17th day of October, 2016.
/s/ Patrick W. O'Brien
(Signature)
Patrick W. O'Brien
(Print name)
