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)
12/14/2010
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3. Issuer Name and Ticker or Trading Symbol
FLEETCOR TECHNOLOGIES INC
[ FLT ]
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
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Director |
X |
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)
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Form filed by One Reporting Person |
| X |
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 |
9,353,417 |
I |
By Chestnut Hill Fuel, LLC
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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 |
1. Name and Address of Reporting Person*
(Street)
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1. Name and Address of Reporting Person*
| C/O CHESTNUT HILL VENTURES LLC |
| 60 WILLIAM STREET, SUITE 230 |
(Street)
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| Explanation of Responses: |
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|
David L. Coombs, as Attorney-in-Fact |
12/14/2010 |
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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
In connection with the ownership, acquisition or disposition of
securities of FleetCor Technologies, Inc. (or any other
securities issued in respect thereof), the undersigned hereby
appoints Timothy B. Bancroft, David L. Coombs and each other
attorney with Goulston & Storrs, P.C., or any of them, its agent
to obtain from the Electronic Data Gathering and Retrieval
system of the United States Securities and Exchange Commission
("SEC") the unique identifiers required to make electronic
filings with the SEC, and to make, subject to the approval of
the undersigned, any electronic filings (or amendments thereto)
pursuant to Sections 13 or 16 of the Securities Exchange Act of
1934, as amended.
IN WITNESS WHEREOF, the undersigned has caused this Power of
Attorney to be executed this 14th day of December, 2010.
CHESTNUT HILL VENTURES LLC
By: /s/ Demos Kouvaris
Name: Demos Kouvaris
Title: COO and CFO
COMMONWEALTH OF MASSACHUSETTS
Location: Norfolk County, Massachusetts, USA
December 14, 2010
On this 14th day of December, 2010, before me, the undersigned
notary public, personally appeared Demos Kouvaris, proved to
me though satisfactory identification, which was [driver's
license] or [based on the undersigned's personal knowledge of
the identity of the principal], to be the person whose name is
signed on the preceding or attached document, and acknowledged
to me that he signed it voluntarily for its stated purpose as a
duly authorized representative of Chestnut Hill Ventures LLC.
/s/ Jessica M. Baldino
Notary Public
My Commission Expires: July 15, 2016
POWER OF ATTORNEY
In connection with the ownership, acquisition or disposition of
securities of FleetCor Technologies, Inc. (or any other
securities issued in respect thereof), the undersigned hereby
appoints Timothy B. Bancroft, David L. Coombs and each other
attorney with Goulston & Storrs, P.C., or any of them, its agent
to obtain from the Electronic Data Gathering and Retrieval
system of the United States Securities and Exchange Commission
("SEC") the unique identifiers required to make electronic
filings with the SEC, and to make, subject to the approval of
the undersigned, any electronic filings (or amendments thereto)
pursuant to Sections 13 or 16 of the Securities Exchange Act of
1934, as amended.
IN WITNESS WHEREOF, the undersigned has caused this Power of
Attorney to be executed this 14th day of December, 2010.
CHESTNUT HILL FUEL, LLC
By: /s/ Demos Kouvaris
Name: Demos Kouvaris
Title: Vice President
COMMONWEALTH OF MASSACHUSETTS
Location: Norfolk County, Massachusetts, USA
December 14, 2010
On this 14th day of December, 2010, before me, the undersigned
notary public, personally appeared Demos Kouvaris, proved to
me though satisfactory identification, which was [driver's
license] or [based on the undersigned's personal knowledge of
the identity of the principal], to be the person whose name is
signed on the preceding or attached document, and acknowledged
to me that he signed it voluntarily for its stated purpose as a
duly authorized representative of Chestnut Hill Fuel, LLC.
/s/ Jessica M. Baldino
Notary Public
My Commission Expires: July 15, 2016
