FORM 3
UNITED STATES SECURITIES AND EXCHANGE COMMISSION
WASHINGTON, DC 20549
INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES
FILED PURSUANT TO SECTION 16(a) OF THE SECURITIES EXCHANGE ACT OF 1934,
SECTION 17(a) OF THE PUBLIC UTILITY HOLDING COMPANY ACT OF 1935 OR
SECTION 30(h) OF THE INVESTMENT COMPANY ACT OF 1940
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1. NAME AND ADDRESS OF REPORTING PERSON*
Bergeron Daniel A.
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(LAST) (FIRST) (MIDDLE)
c/o Allied Healthcare International Inc.
555 Madison Ave.
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(STREET)
New York New York 10022
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(CITY) (STATE) (ZIP)
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2. DATE OF EVENT REQUIRING STATEMENT (MONTH/DAY/YEAR)
Nov. 4, 2002
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3. I.R.S. OR SOCIAL SECURITY NUMBER OF REPORTING PERSON, IF AN
ENTITY (VOLUNTARY)
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4. ISSUER NAME AND TICKER OR TRADING SYMBOL
Allied Healthcare International Inc. (ADH)
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5. RELATIONSHIP OF REPORTING PERSON(S) TO ISSUER
(CHECK ALL APPLICABLE)
|_| DIRECTOR |_| 10% OWNER
|X| OFFICER (GIVE TITLE BELOW) |_| OTHER (SPECIFY BELOW)
CHIEF FINANCIAL OFFICER
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6. IF AMENDMENT, DATE OF ORIGINAL (MONTH/DAY/YEAR)
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7. 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
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3. OWNERSHIP FORM:
2. AMOUNT OF SECURITIES DIRECT (D) OR
1. TITLE OF SECURITY BENEFICIALLY OWNED INDIRECT (I) 4. NATURE OF INDIRECT BENEFICIAL OWNERSHIP
(INSTR. 4) (INSTR. 4) (INSTR. 5) (INSTR. 4)
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No securities are beneficially owned
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* IF THE FORM IS FILED BY MORE THAN ONE REPORTING PERSON, SEE INSTRUCTION 5(b)(v).
REMINDER: REPORT ON A SEPARATE LINE FOR EACH CLASS OF SECURITIES BENEFICIALLY OWNED DIRECTLY OR INDIRECTLY. (OVER)
SEC 1473 (9/96)
FORM 3 (CONTINUED)
TABLE II -- DERIVATIVE SECURITIES BENEFICIALLY OWNED
(E.G., PUTS, CALLS, WARRANTS, OPTIONS, CONVERTIBLE SECURITIES)
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5. OWNER-
3. TITLE AND AMOUNT OF SECURITIES SHIP
UNDERLYING DERIVATIVE SECURITY FORM OF
2. DATE EXERCISABLE (INSTR. 4) DERIVATIVE
AND EXPIRATION DATE --------------------------------- 4. CONVER- SECURITY:
(MONTH/DAY/YEAR) AMOUNT SION OR DIRECT 6. NATURE OF
---------------------- OR EXERCISE (D) OR INDIRECT
DATE EXPIRA- NUMBER PRICE OF INDIRECT BENEFICIAL
1. TITLE OF DERIVATIVE EXER- TION OF DERIVATIVE (I) OWNERSHIP
SECURITY (INSTR. 4) CISABLE DATE TITLE SHARES SECURITY (INSTR. 5) (INSTR. 5)
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EXPLANATION OF RESPONSES:
/S/ DANIEL A. BERGERON NOVEMBER 4, 2002
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**SIGNATURE OF REPORTING PERSON DATE
** INTENTIONAL MISSTATEMENTS OR OMISSIONS OF FACTS CONSTITUTE FEDERAL CRIMINAL
VIOLATIONS. PAGE 2
SEE 18 U.S.C. 1001 AND 15 U.S.C. 78ff(a).