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*
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year) 06/19/2007 |
3. Issuer Name and Ticker or Trading Symbol
Modigene Inc. [ MODG.OB ] |
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
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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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Table I - Non-Derivative Securities Beneficially Owned | |||
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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, par value $0.00001 per share | 1,177,315(1) | D |
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) | 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 | ||||
Stock option (right to buy) | (2) | 12/14/2015 | Common Stock | 170,645 | $0.88 | D | |
Stock option (right to buy) | (3) | 12/14/2015 | Common Stock | 145,048 | $0.88 | D | |
Stock option (right to buy) | (4) | 12/14/2016 | Common Stock | 145,048 | $0.88 | D | |
Stock option (right to buy) | (5) | 05/09/2017 | Common Stock | 200,000 | $2 | D |
Explanation of Responses: |
1. The reporting person acquired 1,177,315 shares of issuer common stock in exchange for 689,920 shares of common stock of Modigene Inc., a Delaware corporation ("Modigene Delaware), pursuant to Modigene Delaware's merger with a wholly-owned subsidiary of the issuer on May 9, 2007 (the "Merger"). Of the 1,177,315 shares issued to the reporting person in the Merger, 58,866 shares are currently being held in escrow and are subject to forfeiture during the two-year period following the Merger to satisfy claims arising as a result of Modigene Delaware's breach of its representations, warranties or covenants in the merger agreement. |
2. Received in connection with the Merger in exchange for an employee stock option to acquire 100,000 shares of Modigene Delaware common stock at $1.50 per share. Option was fully vested at the time of the Merger. |
3. Received in connection with the Merger in exchange for an employee stock option to acquire 85,000 shares of Modigene Delaware common stock at $1.50 per share. Option was fully vested at the time of the Merger. |
4. Received in connection with the Merger in exchange for an employee stock option to acquire 85,000 shares of Modigene Delaware common stock at $1.50 per share. Option was fully vested at the time of the Merger. |
5. Option vests in three equal annual installments beginning May 9, 2008. |
/s/ Shai Novik | 06/19/2007 | |
** 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. |