Orbitz Inc SEC Form 3 Filed December 16, 2003: Initial statement of beneficial ownership of securiti... Last Updated February 7, 2021 at 11:04 PM ST

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Submission Parts

Sequence Document Type File Name Description
1 SEC Form 3
3 SEC Form EX-24

3

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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1. Name and Address of Reporting Person*
SAMUEL JOHN R

(Last) (First) (Middle)
ORBITZ, INC.
200 S. WACKER DRIVE, SUITE 1900

(Street)
CHICAGO IL 60606

(City) (State) (Zip)
2. Date of Event Requiring Statement (Month/Day/Year)
12/16/2003
3. Issuer Name and Ticker or Trading Symbol
ORBITZ INC [ ORBZ ]
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
Director 10% Owner
X Officer (give title below) Other (specify below)
Exec. VP, Consumer Travel
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)
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
Class C Common Stock 08/18/2004(1) (2) Class A Common Stock 33,333 0(3) D
Employee Stock Option (Right to Buy) 08/29/2003(4) 08/29/2013 Class C Common Stock(5) 100,000 13.98 D
Explanation of Responses:
1. Represents shares scheduled to vest equally over 4 years on the anniversary of August 18, 2003.
2. These shares of Class C Common Stock do not have an expiration data, nor do the underlying shares of Class A Common Stock into which these shares of Class C Common Stock will convert, immediately prior to the closing of the Issuer's initial public offering.
3. These securities will automatically convert into shares of Class A Common Stock, par value $.001 per share, on a one-for-one basis immediately prior to the closing of the Issuer's initial public offering.
4. These options vest over four years as follows: 25% will vest on August 29, 2004 and the remaining 75% vest equally over the remaining 36 months.
5. These securities will automatically convert into options to purchase Class A Common Stock par value $.001 per share, on a one-for-one basis immediately prior to the closing of the Issuer's initial public offering.
Remarks:
Exhibit 24 - Confirming Statement
/s/: Richard Buchband, by power of attorney 12/16/2003
** 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.

EX-24

Exhibit 24

 

CONFIRMING STATEMENT

 

This Statement confirms that the undersigned, John R. Samuel, has authorized and designated Richard Buchband or Gary R. Doernhoefer, as the case may be, to execute and file on the undersigned’s behalf all Forms 3, 4 and 5 (including any amendments thereto) that the undersigned may be required to file with the U.S. Securities and Exchange Commission as a result of the undersigned’s ownership of or transactions in securities of Orbitz, Inc.  The authority of Richard Buchband and Gary R. Doernhoefer under this Statement shall continue until the undersigned is no longer required to file Forms 3, 4 and 5 with regard to his ownership of or transactions in securities of Orbitz, Inc., unless earlier revoked in writing.  The undersigned acknowledges that neither Richard Buchband nor Gary R. Doernhoefer is assuming any of the undersigned’s responsibilities to comply with Section 16 of the Securities Exchange Act of 1934.

 

 

Date: December 16, 2003

/s/: John R. Samuel

 

 

John R. Samuel

 

 


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