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