0001562180-19-005865.txt : 20191204 0001562180-19-005865.hdr.sgml : 20191204 20191204172558 ACCESSION NUMBER: 0001562180-19-005865 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 2 CONFORMED PERIOD OF REPORT: 20191203 FILED AS OF DATE: 20191204 DATE AS OF CHANGE: 20191204 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: HILLEMAN JERYL L CENTRAL INDEX KEY: 0001216628 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38701 FILM NUMBER: 191268898 MAIL ADDRESS: STREET 1: C/O INTERSECT ENT, INC. STREET 2: 1555 ADAMS DRIVE CITY: MENLO PARK STATE: CA ZIP: 94025 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: SI-BONE, Inc. CENTRAL INDEX KEY: 0001459839 STANDARD INDUSTRIAL CLASSIFICATION: SURGICAL & MEDICAL INSTRUMENTS & APPARATUS [3841] IRS NUMBER: 262216351 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 471 EL CAMINO REAL, SUITE 101 CITY: SANTA CLARA STATE: CA ZIP: 95050 BUSINESS PHONE: 4082070700 MAIL ADDRESS: STREET 1: 471 EL CAMINO REAL, SUITE 101 CITY: SANTA CLARA STATE: CA ZIP: 95050 FORMER COMPANY: FORMER CONFORMED NAME: SI-Bone Inc. DATE OF NAME CHANGE: 20090326 4 1 primarydocument.xml PRIMARY DOCUMENT X0306 4 2019-12-03 false 0001459839 SI-BONE, Inc. SIBN 0001216628 HILLEMAN JERYL L C/O SI-BONE, INC. 471 EL CAMINO REAL, SUITE 101 SANTA CLARA CA 95050 true false false false Stock Options (Right to buy) 17.31 2019-12-03 4 A false 26236.00 0.00 A 2029-12-02 Common Stock 26236.00 26236.00 D The shares subject to the option will vest in a series of 12 equal monthly increments over the one-year period following the Vesting Commencement Date, such that the option will be fully vested on the first anniversary of the Vesting Commencement Date, subject to the Reporting Person's continuous service as a member of the Issuer's Board of Directors on such applicable vesting date. /s /Michael Pisetsky, Attorney-in-Fact for Jeryl L Hilleman 2019-12-04 EX-24 2 jhillemanpoa.txt POA POWER OF ATTORNEY Know all by these presents, that the undersigned hereby constitutes and appoints each of LAURA A. FRANCIS, MICHAEL A. PISETSKY, MATTHEW B. HEMINGTON and JOHN T. MCKENNA, signing individually, the undersigned's true and lawful attorneys-in- fact and agents to: (1) execute for and on behalf of the undersigned, in the undersigned's capacity as an officer, director or beneficial owner of more than 10% of a registered class of securities of SI-BONE, INC. (the "Company"), Forms 3, 4 and 5 (including any amendments thereto) in accordance with Section 16(a) of the Securities Exchange Act of 1934, as amended (the "Exchange Act") and the rules thereunder and a Form ID, Uniform Application for Access Codes to File on EDGAR; (2) do and perform any and all acts for and on behalf of the undersigned that may be necessary or desirable to execute such Forms 3, 4 or 5 or Form ID (including any amendments thereto) and timely file such forms with the United States Securities and Exchange Commission and any stock exchange or similar authority; and (3) take any other action of any nature whatsoever in connection with the foregoing which, in the opinion of such attorney-in-fact, may be of benefit, in the best interest of, or legally required by, the undersigned, it being understood that the documents executed by such attorney-in-fact on behalf of the undersigned pursuant to this 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 any 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, with full power of substitution or revocation, hereby ratifying and confirming all that such attorney-in-fact, or such attorney -in-fact's substitute or substitutes, shall lawfully do or cause to be done by virtue of this 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, nor is the Company assuming, any of the undersigned's responsibilities to comply with Section 16 of the Exchange Act. This Power of Attorney shall remain in full force and effect until the earliest to occur of (a) the undersigned is no longer required to file Forms 3, 4 and 5 with respect to the undersigned's holdings of and transactions in securities issued by the Company, (b) revocation by the undersigned in a signed writing delivered to the foregoing attorneys-in-fact or (c) as to any attorney-in-fact individually, until such attorney-in-fact is no longer employed by the Company or Cooley LLP. IN WITNESS WHEREOF, the undersigned has caused this Power of Attorney to be executed as of December 3, 2019. /s/ Jeryl L. Hilleman Jeryl L. Hilleman