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