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*
Larkin Richard J

(Last) (First) (Middle)
3661 HORSEBLOCK ROAD

(Street)
MEDFORD NY 11763

(City) (State) (Zip)
2. Date of Event Requiring Statement (Month/Day/Year)
05/05/2004
3. Issuer Name and Ticker or Trading Symbol
Chembio Diagnostics Inc. [ CEMI ]
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
Director 10% Owner
X Officer (give title below) Other (specify below)
Chief Financial Officer
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(1) 2,500 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
8% Series A Convertible Preferred Stock(2) 05/05/2004 12/31/2049 Common Stock 25,196 (3) D
Option to purchase Common Stock(1) 05/05/2004 09/15/2010 Common Stock 50,000 0.45 D
Warrant to purchase Common Stock(2) 05/05/2004 05/04/2009 Common Stock 30,236 0.9 D
Warrant to purchase Common Stock(1) 05/05/2004 05/04/2009 Common Stock 250 0.9 D
Explanation of Responses:
1. On May 5, 2004, the Issuer acquired Chembio Diagnostics Systems Inc., a privately held corporation ("Chembio"), through a merger of a wholly owned subsidiary of the Issuer with and into Chembio. Pursuant to the terms of the merger, each stockholder of Chembio received shares of the Issuer's Common Stock in exchange for Chembio common stock owned. The Issuer also assumed all the outstanding warrants and options to acquire Chembio common stock. Each assumed warrant and option is now exercisable for shares of the Issuer's Common Stock. Mr. Larkin received 2,500 shares of the Issuer's Common Stock in exchange for his Chembio common stock and received warrants to purchase 250 shares of the Issuer's Common Stock and options to purchase 50,000 shares of the Issuer's Common Stock in exchange for warrants and options, respectively, that he held of Chembio.
2. On May 5, 2004, the Issuer consummated a private offering of its 8% Series A Convertible Preferred Stock (together with warrants to purchase shares of its Common Stock) in exchange for certain indebtedness of Chembio that was previously outstanding. The conversion price at which such debt was exchanged into 8% Series A Convertible Preferred Stock (together with warrants to purchase shares of the Issuer's Common Stock) was $30,000 per share. Mr. Larkin converted $10,117.81 of Chembio indebtedness that he held prior to the merger into .50392 shares Series A Convertible Preferred Stock (together with warrants to purchase 30,236 shares of Common Stock)pursuant to the Series A Offering.
3. 50,000 to 1
Richard J. Larkin 07/01/2004
** 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).
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