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*
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year)
12/02/2014
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3. Issuer Name and Ticker or Trading Symbol
Zumiez Inc
[ ZUMZ ]
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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 |
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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)
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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)
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|---|
| 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: |
|
Chris K. Visser, Attorney-In-Fact |
12/04/2014 |
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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
1. Designation of Attorneys-in-Fact. The
undersigned, hereby designates each of Chris K. Visser
and Kristy T. Harlan, individuals with full power of
substitution, as my attorney-in-fact to act for me and
in my name, place and stead, and on my behalf in
connection with the matters set forth in Item 2 below.
2. Powers of Attorney-in-Fact. Each attorney-
in-fact, as fiduciary, shall have the authority to sign
all such U.S. Securities and Exchange Commission
("SEC") reports, forms and other filings, specifically
including but not limited to Forms 3, 4, 5 and 144, as
such attorney-in-fact deems necessary or desirable in
connection with the satisfaction of my reporting
obligations under the rules and regulations of the SEC.
3. Effectiveness. This power of attorney shall
become effective upon the execution of this document.
4. Duration. This power of attorney shall
remain in effect until revoked by me. This power of
attorney shall not be affected by disability of the
principal.
5. Revocation. This power of attorney may be
revoked in writing at any time by my giving written
notice to the attorney-in-fact. If this power of
attorney has been recorded, the written notice of
revocation shall also be recorded.
Date: November 21, 2014.
__Kalen Holmes____
Kalen Holmes
STATE OF Washington )
COUNTY OF Snohomish )
SIGNED OR ATTESTED before me on 11/21/14.
__Sharon D. Kamprath________
Signature of Notary Public
_Sharon D. Kamprath_____
(SEAL) Typed Name of Notary Public
Residing at:Lynnwood, WA
My commission expires: _2/23/15_
