0001140361-17-038672.txt : 20171013
0001140361-17-038672.hdr.sgml : 20171013
20171013191116
ACCESSION NUMBER: 0001140361-17-038672
CONFORMED SUBMISSION TYPE: 4
PUBLIC DOCUMENT COUNT: 1
CONFORMED PERIOD OF REPORT: 20171011
FILED AS OF DATE: 20171013
DATE AS OF CHANGE: 20171013
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: Di Bona Tony
CENTRAL INDEX KEY: 0001316825
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-38238
FILM NUMBER: 171137401
MAIL ADDRESS:
STREET 1: 400 HAMILTON AVENUE
STREET 2: 4TH FLOOR
CITY: PALO ALTO
STATE: CA
ZIP: 94301
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: Hanafi Ammar
CENTRAL INDEX KEY: 0001316968
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-38238
FILM NUMBER: 171137398
MAIL ADDRESS:
STREET 1: 400 HAMILTON AVENUE
STREET 2: 4TH FLOOR
CITY: PALO ALTO
STATE: CA
ZIP: 94301
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: Hunkapiller Michael
CENTRAL INDEX KEY: 0001317102
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-38238
FILM NUMBER: 171137399
MAIL ADDRESS:
STREET 1: 400 HAMILTON AVENUE
STREET 2: 4TH FLOOR
CITY: PALO ALTO
STATE: CA
ZIP: 94301
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: Rubin Daniel
CENTRAL INDEX KEY: 0001316624
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-38238
FILM NUMBER: 171137400
MAIL ADDRESS:
STREET 1: 480 COWPER ST.
STREET 2: 2ND FL.
CITY: PALO ALTO
STATE: CA
ZIP: 94301
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: Shoch John
CENTRAL INDEX KEY: 0001316618
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-38238
FILM NUMBER: 171137402
MAIL ADDRESS:
STREET 1: 400 HAMILTON AVENUE
STREET 2: 4TH FLOOR
CITY: PALO ALTO
STATE: CA
ZIP: 94301
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: KELLY DOUGLAS E
CENTRAL INDEX KEY: 0001227887
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-38238
FILM NUMBER: 171137403
MAIL ADDRESS:
STREET 1: 400 HAMILTON AVENUE
STREET 2: 4TH FLOOR
CITY: PALO ALTO
STATE: CA
ZIP: 94301
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: ALLOY VENTURES 2002 LLC
CENTRAL INDEX KEY: 0001176013
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-38238
FILM NUMBER: 171137404
BUSINESS ADDRESS:
STREET 1: 400 HAMILTON AVENUE
STREET 2: 4TH FLOOR
CITY: PALO ALTO
STATE: CA
ZIP: 94301
BUSINESS PHONE: 650-687-5000
MAIL ADDRESS:
STREET 1: 400 HAMILTON AVENUE
STREET 2: 4TH FLOOR
CITY: PALO ALTO
STATE: CA
ZIP: 94301
ISSUER:
COMPANY DATA:
COMPANY CONFORMED NAME: Restoration Robotics Inc
CENTRAL INDEX KEY: 0001409269
STANDARD INDUSTRIAL CLASSIFICATION: SURGICAL & MEDICAL INSTRUMENTS & APPARATUS [3841]
IRS NUMBER: 061681204
FISCAL YEAR END: 1231
BUSINESS ADDRESS:
STREET 1: 128 BAYTECH DRIVE
CITY: SAN JOSE
STATE: CA
ZIP: 95134
BUSINESS PHONE: 408-883-6888
MAIL ADDRESS:
STREET 1: 128 BAYTECH DRIVE
CITY: SAN JOSE
STATE: CA
ZIP: 95134
4
1
doc1.xml
FORM 4
X0306
4
2017-10-11
0
0001409269
Restoration Robotics Inc
HAIR
0001176013
ALLOY VENTURES 2002 LLC
1415 HAMILTON AVENUE
PALO ALTO
CA
94301
0
0
1
0
0001227887
KELLY DOUGLAS E
400 HAMILTON AVENUE 4TH FLOOR
PALO ALTO
CA
94301
0
0
1
0
0001316618
Shoch John
400 HAMILTON AVENUE 4TH FLOOR
PALO ALTO
CA
94301
0
0
1
0
0001316825
Di Bona Tony
400 HAMILTON AVENUE 4TH FLOOR
PALO ALTO
CA
94301
0
0
1
0
0001316624
Rubin Daniel
400 HAMILTON AVENUE 4TH FLOOR
PALO ALTO
CA
94301
0
0
1
0
0001317102
Hunkapiller Michael
400 HAMILTON AVENUE 4TH FLOOR
PALO ALTO
CA
94301
0
0
1
0
0001316968
Hanafi Ammar
400 HAMILTON AVENUE 4TH FLOOR
PALO ALTO
CA
94301
0
0
1
0
Convertible Promissory Note
7
2017-10-11
4
J
0
15888.66
15888.66
A
Common Stock
15888.66
I
See Footnote
Convertible Promissory Note
7
2017-10-11
4
J
0
588463.1
588463.1
A
Common Stock
588463.1
I
See Footnote
Convertible Promissory Note
7
2017-10-11
4
J
0
604351.76
604351.76
A
Common Stock
604351.76
I
See Footnote
The securities were originally acquired from the Issuer on September 6, 2017; however, the conversion price was set upon the pricing of the Issuer's Initial Public Offering (the "IPO").
The amount reported represents the principal amount of the Reporting Person's Convertible Promissory Note (the "Note") only. Accrued interest of 5% per year based on the actual number of days outstanding through the conversion date will also convert.
The outstanding principal and accrued interest of the Note automatically converts into shares of the Issuer's Common Stock at the price per share available to the public as set forth in the final prospectus related to the IPO upon the closing of the IPO; if not so converted, the Note has a maturity date of September 6, 2018, at which time it will automatically convert into shares of the Issuer's capital stock.
See additional Form 4 filed by Alloy Ventures 2002, LLC ("Ventures 2002") for additional members of this joint filing. The securities are directly held by Alloy Partners 2002, L.P. ("Alloy Partners 2002"). Ventures 2002, as the sole general partner of Alloy Partners 2002, may be deemed to beneficially own the securities held by Alloy Partners 2002. Craig Taylor, Douglas Kelly, John Shoch, Tony DiBona and Daniel Rubin are managing directors of Ventures 2002, and as such may be deemed to beneficially own the securities held by Alloy Partners 2002. Each Reporting Person disclaims beneficial ownership of such securities except to the extent of any pecuniary interest therein.
See additional Form 4 filed by Ventures 2002 for additional members of this joint filing. The securities are directly held by Alloy Ventures 2002, L.P. ("Alloy Ventures 2002"). Ventures 2002, as the sole general partner of Alloy Ventures 2002, may be deemed to beneficially own the securities held by Alloy Ventures 2002. Craig Taylor, Douglas Kelly, John Shoch, Tony DiBona and Daniel Rubin are managing directors of Ventures 2002, and as such may be deemed to beneficially own the securities held by Alloy Ventures 2002. Each Reporting Person disclaims beneficial ownership of such securities except to the extent of any pecuniary interest therein.
See additional Form 4 filed by Ventures 2002 for additional members of this joint filing. The securities are directly held by Alloy Ventures 2005, L.P. ("Alloy Ventures 2005"). Alloy Ventures 2005, LLC ("Ventures 2005"), as the sole general partner of Alloy Ventures 2005, may be deemed to beneficially own the securities held by Alloy Ventures 2005. Craig Taylor, Douglas Kelly, John Shoch, Tony DiBona, Daniel Rubin, Michael Hunkapiller and Ammar H. Hanafi are managing directors of Ventures 2005, and as such may be deemed to beneficially own the securities held by Alloy Ventures 2005. Each Reporting Person disclaims beneficial ownership of such securities except to the extent of any pecuniary interest therein.
/s/ Tony Di Bona, managing member of Alloy Ventures 2002, LLC
2017-10-13
/s/ Tony Di Bona, attorney-in-fact for Douglas E. Kelly
2017-10-13
/s/ Tony Di Bona, attorney-in-fact for John F. Shoch
2017-10-13
/s/ Tony Di Bona, attorney-in-fact for Michael W. Hunkapiller
2017-10-13
/s/ Tony Di Bona, attorney-in-fact for Daniel I. Rubin
2017-10-13
/s/ Tony Di Bona, attorney-in-fact for Ammar H. Hanafi
2017-10-13
/s/ Tony Di Bona
2017-10-13