0001209191-19-023233.txt : 20190403 0001209191-19-023233.hdr.sgml : 20190403 20190403165142 ACCESSION NUMBER: 0001209191-19-023233 CONFORMED SUBMISSION TYPE: 3 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20190403 FILED AS OF DATE: 20190403 DATE AS OF CHANGE: 20190403 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Norwest Venture Partners XIII, LP CENTRAL INDEX KEY: 0001772583 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38847 FILM NUMBER: 19729707 BUSINESS ADDRESS: STREET 1: 525 UNIVERSITY AVENUE, SUITE 800 CITY: PALO ALTO STATE: CA ZIP: 94301 BUSINESS PHONE: (650)321-8000 MAIL ADDRESS: STREET 1: 525 UNIVERSITY AVENUE, SUITE 800 CITY: PALO ALTO STATE: CA ZIP: 94301 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Crowe Jeffrey CENTRAL INDEX KEY: 0001535261 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38847 FILM NUMBER: 19729708 MAIL ADDRESS: STREET 1: 525 UNIVERSITY AVENUE STREET 2: SUITE 800 CITY: PALO ALTO STATE: CA ZIP: 94301 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Kossow Jon Erik CENTRAL INDEX KEY: 0001726084 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38847 FILM NUMBER: 19729709 MAIL ADDRESS: STREET 1: 525 UNIVERSITY AVENUE, SUITE 800 CITY: PALO ALTO STATE: CA ZIP: 94025 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: HAQUE PROMOD CENTRAL INDEX KEY: 0001089744 STATE OF INCORPORATION: CA FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38847 FILM NUMBER: 19729710 MAIL ADDRESS: STREET 1: C/O NORWEST VENTURE PARTNERS STREET 2: 525 UNIVERSITY AVENUE, SUITE 800 CITY: PALO ALTO STATE: CA ZIP: 94301 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: Silk Road Medical Inc CENTRAL INDEX KEY: 0001397702 STANDARD INDUSTRIAL CLASSIFICATION: SURGICAL & MEDICAL INSTRUMENTS & APPARATUS [3841] IRS NUMBER: 208777622 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 1213 INNSBRUCK DR. CITY: SUNNYVALE STATE: CA ZIP: 94089-2918 BUSINESS PHONE: 6505669060 MAIL ADDRESS: STREET 1: 1213 INNSBRUCK DR. CITY: SUNNYVALE STATE: CA ZIP: 94089-2918 3 1 doc3.xml FORM 3 SUBMISSION X0206 3 2019-04-03 0 0001397702 Silk Road Medical Inc SILK 0001772583 Norwest Venture Partners XIII, LP 525 UNIVERSITY AVENUE SUITE 800 PALO ALTO CA 94301 0 0 1 0 0001535261 Crowe Jeffrey 525 UNIVERSITY AVENUE SUITE 800 PALO ALTO CA 94301 0 0 1 0 0001726084 Kossow Jon Erik 525 UNIVERSITY AVENUE SUITE 800 PALO ALTO CA 94301 0 0 1 0 0001089744 HAQUE PROMOD 525 UNIVERSITY AVENUE SUITE 800 PALO ALTO CA 94301 0 0 1 0 Series C Preferred Stock Common Stock 2458210 D Warrant (Right to buy) 8.27 2024-12-21 Common Stock 3764 D The securities shown on Lines 1 and 2 of Table II represent securities held of record by Norwest Venture Partners XIII, LP ("NVP XIII"). Genesis VC Partners XIII, LLC ("Genesis XIII") is the general partner of NVP XIII and may be deemed to have sole voting and dispositive power over the shares held by NVP XIII. NVP Associates, LLC ("NVP Associates"), the managing member of Genesis XIII, and Promod Haque, Jeffrey Crow and Jon E. Kossow, as Co-Chief Executive Officers of NVP Associates, may be deemed to share voting and dispositive power with respect to such securities. Such entities and Haque, Crowe, and Kossow disclaim beneficial ownership of all such securities, except to the extent of any pecuniary interest therein. The Series C Preferred Stock shall automatically convert into Common Stock on a 1:1 basis immediately prior to the completion of the Issuer's initial public offering of Common Stock and has no expiration date. All of the shares subject to this warrant are fully vested and exercisable as of the date hereof. /s/ Matthew De Dominicis, Chief Financial Officer 2019-04-03