0001209191-21-028017.txt : 20210422
0001209191-21-028017.hdr.sgml : 20210422
20210422192941
ACCESSION NUMBER: 0001209191-21-028017
CONFORMED SUBMISSION TYPE: 3
PUBLIC DOCUMENT COUNT: 2
CONFORMED PERIOD OF REPORT: 20210422
FILED AS OF DATE: 20210422
DATE AS OF CHANGE: 20210422
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: 001-40353
FILM NUMBER: 21846312
MAIL ADDRESS:
STREET 1: C/O NORWEST VENTURE PARTNERS
STREET 2: 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: 001-40353
FILM NUMBER: 21846313
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: Norwest Venture Partners XIV, LP
CENTRAL INDEX KEY: 0001842721
STATE OF INCORPORATION: DE
FISCAL YEAR END: 1231
FILING VALUES:
FORM TYPE: 3
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-40353
FILM NUMBER: 21846314
BUSINESS ADDRESS:
STREET 1: 525 UNIVERSITY AVENUE
STREET 2: SUITE 800
CITY: PALO ALTO
STATE: CA
ZIP: 94301
BUSINESS PHONE: 650-321-8000
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: 001-40353
FILM NUMBER: 21846311
MAIL ADDRESS:
STREET 1: 525 UNIVERSITY AVENUE, SUITE 800
CITY: PALO ALTO
STATE: CA
ZIP: 94025
ISSUER:
COMPANY DATA:
COMPANY CONFORMED NAME: IMPEL NEUROPHARMA INC
CENTRAL INDEX KEY: 0001445499
STANDARD INDUSTRIAL CLASSIFICATION: PHARMACEUTICAL PREPARATIONS [2834]
IRS NUMBER: 263058238
STATE OF INCORPORATION: DE
FISCAL YEAR END: 1231
BUSINESS ADDRESS:
STREET 1: 201 ELLIOTT AVE. W
STREET 2: SUITE 260
CITY: SEATTLE
STATE: WA
ZIP: 98119
BUSINESS PHONE: 206-568-1466
MAIL ADDRESS:
STREET 1: 201 ELLIOTT AVE. W
STREET 2: SUITE 260
CITY: SEATTLE
STATE: WA
ZIP: 98119
3
1
doc3.xml
FORM 3 SUBMISSION
X0206
3
2021-04-22
0
0001445499
IMPEL NEUROPHARMA INC
IMPL
0001842721
Norwest Venture Partners XIV, 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
0001089744
HAQUE PROMOD
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
Series D Convertible Preferred Stock
Common Stock
2153271
D
The securities shown represent securities held of record by Norwest Venture Partners XIV, LP ("NVP XIV"). Genesis VC Partners XIV, LLC ("Genesis XIV") is the general partner of NVP XIV and may be deemed to have sole voting and dispositive power over the shares held by NVP XIV. NVP Associates, LLC ("NVP Associates"), the managing member of Genesis XIV, and Jeffrey Crowe, Promod Haque 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 Messrs. Crowe, Haque and Kossow disclaim beneficial ownership of all such securities, except to the extent of any pecuniary interest therein.
The shares of the Issuer's Series D Preferred Stock will automatically convert on a 16.37332-for-one basis into the number of shares of the Issuer's Common Stock shown in column 3 immediately prior to the completion of the Issuer's initial public offering of Common Stock and has no expiration date.
/s/ Matthew De Dominicis, Chief Financial Officer
2021-04-22
/s/ Matthew De Dominicis, Attorney-in-Fact for Jeffrey Crowe
2021-04-22
/s/ Matthew De Dominicis, Attorney-in-Fact for Promod Haque
2021-04-22
/s/ Matthew De Dominicis, Attorney-in-Fact for Jon Erik Kossow
2021-04-22
EX-24.3_980519
2
poa.txt
POA DOCUMENT
LIMITEDPOWER OF ATTORNEY
FOR
SECTION 16 AND SECTION REPORTING OBLIGATIONS
Know all by these present, that the undersigned hereby constitutes and appoints
Matthew De Dominicis, the undersigned's true and lawful attorneys-in-fact, with
full power and authority as hereinafter described on behalf of and in the name,
place and stead of the undersigned t to:
(1) prepare, execute, acknowledge and deliver, for and on behalf of the
undersigned, all reports and filings required by (a) Section 16(a) of the
Securities Exchange Act of 1934 and the rules promulgated thereunder (the
"Section 16 Reports") and (b) Section 13 of the Securities and Exchange Act of
1934 and the rules promulgated thereunder (the "Section 13 Reports").
(2) do and perform any and all acts for and on behalf of the undersigned which
may be necessary or desirable to file any such Section 16 Reports and Section 13
Reports, or any amendments thereto, with the United States Securities and
Exchange Commission and any other authority; and
(3) take any other action of any type whatsoever in connection with the
foregoing which, in the opinion of such attorney-in-fact, may be of benefit to,
in the best interest of or legally required of the undersigned, it being
understood that the documents executed by such attorney in fact on behalf of the
undersigned pursuant to this Limited Power of Attorney shall be in such form and
shall contain such terms and conditions as such attorney in fact may approve in
such attorney in fact's discretion.
The undersigned hereby grants to each such attorney-in-fact full power and
authority to do and perform each and every act and thing whatsoever requisite,
necessary or proper to be done in the exercise of any of the rights and powers
herein granted, as fully to all intents and purposes as the undersigned might or
could do if personally present and acting, with full power of substitution or
revocation, hereby ratifying and confirming all that such attorney-in-fact, or
his substitute or substitutes, shall lawfully do or cause to be done by virtue
of this Limited Power of Attorney and the rights and powers herein granted. The
undersigned acknowledges that the foregoing attorneys-in-fact, in serving in
such capacity at the request of the undersigned, are not assuming any of the
undersigned's responsibilities to comply with Section 16 and Section 13 of the
Securities Exchange Act of 1934, as amended.
This Limited Power of Attorney shall not revoke any previous Limited Power of
Attorney granted by the undersigned with respect to the subject matter hereof,
and shall remain in full force and effect until the undersigned is no longer
required to file Section 16 Reports and Section 13 Reports, unless earlier
revoked by the undersigned in a subsequently executed Limited Power of Attorney
or a signed writing delivered to the foregoing attorneys-in-fact.
IN WITNESS WHEREOF, the undersigned has caused this Power of Attorney to be
executed as of this 20th day of December, 2017.
/s/ Jon E. Kossow
Signature
Jon E. Kossow
Print Name
LIMITEDPOWER OF ATTORNEY
FOR
SECTION 16 AND SECTION REPORTING OBLIGATIONS
Know all by these present, that the undersigned hereby constitutes and appoints
Matthew De Dominicis, the undersigned's true and lawful attorneys-in-fact, with
full power and authority as hereinafter described on behalf of and in the name,
place and stead of the undersigned t to:
(1) prepare, execute, acknowledge and deliver, for and on behalf of the
undersigned, all reports and filings required by (a) Section 16(a) of the
Securities Exchange Act of 1934 and the rules promulgated thereunder (the
"Section 16 Reports") and (b) Section 13 of the Securities and Exchange Act of
1934 and the rules promulgated thereunder (the "Section 13 Reports").
(2) do and perform any and all acts for and on behalf of the undersigned which
may be necessary or desirable to file any such Section 16 Reports and Section 13
Reports, or any amendments thereto, with the United States Securities and
Exchange Commission and any other authority; and
(3) take any other action of any type whatsoever in connection with the
foregoing which, in the opinion of such attorney-in-fact, may be of benefit to,
in the best interest of or legally required of the undersigned, it being
understood that the documents executed by such attorney in fact on behalf of the
undersigned pursuant to this Limited Power of Attorney shall be in such form and
shall contain such terms and conditions as such attorney in fact may approve in
such attorney in fact's discretion.
The undersigned hereby grants to each such attorney-in-fact full power and
authority to do and perform each and every act and thing whatsoever requisite,
necessary or proper to be done in the exercise of any of the rights and powers
herein granted, as fully to all intents and purposes as the undersigned might or
could do if personally present and acting, with full power of substitution or
revocation, hereby ratifying and confirming all that such attorney-in-fact, or
his substitute or substitutes, shall lawfully do or cause to be done by virtue
of this Limited Power of Attorney and the rights and powers herein granted. The
undersigned acknowledges that the foregoing attorneys-in-fact, in serving in
such capacity at the request of the undersigned, are not assuming any of the
undersigned's responsibilities to comply with Section 16 and Section 13 of the
Securities Exchange Act of 1934, as amended.
This Limited Power of Attorney shall not revoke any previous Limited Power of
Attorney granted by the undersigned with respect to the subject matter hereof,
and shall remain in full force and effect until the undersigned is no longer
required to file Section 16 Reports and Section 13 Reports, unless earlier
revoked by the undersigned in a subsequently executed Limited Power of Attorney
or a signed writing delivered to the foregoing attorneys-in-fact.
IN WITNESS WHEREOF, the undersigned has caused this Power of Attorney to be
executed as of this 20th day of June, 2017.
/s/ Promod Haque
Signature
Promod Haque
Print Name
LIMITEDPOWER OF ATTORNEY
FOR
SECTION 16 AND SECTION REPORTING OBLIGATIONS
Know all by these present, that the undersigned hereby constitutes and appoints
Matthew De Dominicis, the undersigned's true and lawful attorneys-in-fact, with
full power and authority as hereinafter described on behalf of and in the name,
place and stead of the undersigned t to:
(1) prepare, execute, acknowledge and deliver, for and on behalf of the
undersigned, all reports and filings required by (a) Section 16(a) of the
Securities Exchange Act of 1934 and the rules promulgated thereunder (the
"Section 16 Reports") and (b) Section 13 of the Securities and Exchange Act of
1934 and the rules promulgated thereunder (the "Section 13 Reports").
(2) do and perform any and all acts for and on behalf of the undersigned which
may be necessary or desirable to file any such Section 16 Reports and Section 13
Reports, or any amendments thereto, with the United States Securities and
Exchange Commission and any other authority; and
(3) take any other action of any type whatsoever in connection with the
foregoing which, in the opinion of such attorney-in-fact, may be of benefit to,
in the best interest of or legally required of the undersigned, it being
understood that the documents executed by such attorney in fact on behalf of the
undersigned pursuant to this Limited Power of Attorney shall be in such form and
shall contain such terms and conditions as such attorney in fact may approve in
such attorney in fact's discretion.
The undersigned hereby grants to each such attorney-in-fact full power and
authority to do and perform each and every act and thing whatsoever requisite,
necessary or proper to be done in the exercise of any of the rights and powers
herein granted, as fully to all intents and purposes as the undersigned might or
could do if personally present and acting, with full power of substitution or
revocation, hereby ratifying and confirming all that such attorney-in-fact, or
his substitute or substitutes, shall lawfully do or cause to be done by virtue
of this Limited Power of Attorney and the rights and powers herein granted. The
undersigned acknowledges that the foregoing attorneys-in-fact, in serving in
such capacity at the request of the undersigned, are not assuming any of the
undersigned's responsibilities to comply with Section 16 and Section 13 of the
Securities Exchange Act of 1934, as amended.
This Limited Power of Attorney shall not revoke any previous Limited Power of
Attorney granted by the undersigned with respect to the subject matter hereof,
and shall remain in full force and effect until the undersigned is no longer
required to file Section 16 Reports and Section 13 Reports, unless earlier
revoked by the undersigned in a subsequently executed Limited Power of Attorney
or a signed writing delivered to the foregoing attorneys-in-fact.
IN WITNESS WHEREOF, the undersigned has caused this Power of Attorney to be
executed as of this 20th day of June, 2017.
/s/ Jeffrey M. Crowe
Signature
Jeffrey M. Crowe
Print Name