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*
FERRARI RICHARD M

(Last) (First) (Middle)
C/O PULMONX CORPORATION
700 CHESAPEAKE DRIVE

(Street)
REDWOOD CITY CA 94063

(City) (State) (Zip)
2. Date of Event Requiring Statement (Month/Day/Year)
09/30/2020
3. Issuer Name and Ticker or Trading Symbol
Pulmonx Corp [ LUNG ]
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
X Director 10% Owner
Officer (give title below) Other (specify below)
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 10,832 I See Footnote(1)
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
Series A-1 Preferred Stock (2) (2) Common Stock 26,266 (2) I See Footnote(1)
Series B-1 Preferred Stock (2) (2) Common Stock 675,227 (2) I See Footnote(1)
Series C-1 Preferred Stock (2) (2) Common Stock 327,560 (2) I See Footnote(1)
Series D-1 Preferred Stock (2) (2) Common Stock 126,603 (2) I See Footnote(1)
Series E-1 Preferred Stock (2) (2) Common Stock 65,833 (2) I See Footnote(1)
Explanation of Responses:
1. The shares are directly held by De Novo Ventures III Liquidating Trust ("De Novo"). The Reporting Person, along with Fred Dozier and Joseph Mandato, and Jay Watkins are the trustees of De Novo and exercise shared voting and dispositive control over the shares held by De Novo.
2. Each share of Preferred Stock automatically converts on a one-for-one basis into Common Stock at any time at the holder's election and automatically upon the closing of the Issuer's initial public offering, for no additional consideration. The Preferred Stock has no expiration date.
Remarks:
Exhibit List - Exhibit 24 - Power of Attorney
/s/ Mark Weeks, Attorney-In-Fact 09/30/2020
** 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.
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