0000899243-18-027735.txt : 20181030 0000899243-18-027735.hdr.sgml : 20181030 20181030212455 ACCESSION NUMBER: 0000899243-18-027735 CONFORMED SUBMISSION TYPE: 3 PUBLIC DOCUMENT COUNT: 2 CONFORMED PERIOD OF REPORT: 20181030 FILED AS OF DATE: 20181030 DATE AS OF CHANGE: 20181030 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Ford Alfred J Jr CENTRAL INDEX KEY: 0001359446 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38721 FILM NUMBER: 181148497 MAIL ADDRESS: STREET 1: 3303 MONTE VILLA PARKWAY CITY: BOTHELL STATE: WA ZIP: 98021 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: Axonics Modulation Technologies, Inc. CENTRAL INDEX KEY: 0001603756 STANDARD INDUSTRIAL CLASSIFICATION: SURGICAL & MEDICAL INSTRUMENTS & APPARATUS [3841] IRS NUMBER: 454744083 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 26 TECHNOLOGY DRIVE CITY: IRVINE STATE: CA ZIP: 92618 BUSINESS PHONE: 949-396-6322 MAIL ADDRESS: STREET 1: 26 TECHNOLOGY DRIVE CITY: IRVINE STATE: CA ZIP: 92618 3 1 doc3.xml FORM 3 SUBMISSION X0206 3 2018-10-30 0 0001603756 Axonics Modulation Technologies, Inc. AXNX 0001359446 Ford Alfred J Jr 26 TECHNOLOGY DRIVE IRVINE CA 92618 0 1 0 0 Chief Commercial Officer Stock Option (Right to Buy) 1.42 2027-11-15 Common Stock 58380 D Stock Option (Right to Buy) 1.63 2028-03-30 Common Stock 7620 D The shares subject to the option will vest over a period of four years, with 1/4th of the shares subject to the option vesting on November 15, 2017 and the remainder vesting at a rate of 1/36th per month commencing upon the one-year anniversary of November 15, 2017, provided the reporting person remains in continuous service on each vesting date, subject to accelerated vesting in certain events, including upon certain changes of control of the Issuer. The option is subject to an early exercise provision and is immediately exercisable. Reflects a 1.2-for-1 forward stock split of the Issuer's common stock effected on October 18, 2018. The shares subject to the option will vest over a period of four years, with 1/4th of the shares subject to the option vesting on March 30, 2018 and the remainder vesting at a rate of 1/36th per month commencing upon the one-year anniversary of March 30, 2018, provided the reporting person remains in continuous service on each vesting date, subject to accelerated vesting in certain events, including upon certain changes of control of the Issuer. The option is subject to an early exercise provision and is immediately exercisable. Exhibit List: Exhibit 24.1 - Power of Attorney /s/ Michael V. Williamson, as Attorney-in-Fact for Alfred J. Ford, Jr. 2018-10-30 EX-24.1 2 attachment1.htm EX-24.1 DOCUMENT

                                  POWER OF ATTORNEY

      Know all by these presents, that the undersigned hereby constitutes and
appoints each of Michael V. Williamson, Danny L. Dearen, and Michael A. Hedge,
signing singly, as the undersigned's true and lawful attorney-in-fact to:

      (1)    execute for and on behalf of the undersigned, in the undersigned's
             capacity as an officer and/or director of Axonics Modulation
             Technologies, Inc. (the "Company"), a Form ID and Forms 3, 4 and 5
             in accordance with Section 16(a) of the Securities Exchange Act of
             1934, as amended, and the rules thereunder;

      (2)    do and perform any and all acts for and on behalf of the
             undersigned which may be necessary or desirable to complete and
             execute any such Form ID, 3, 4 or 5 and file such form with the
             United States Securities and Exchange Commission and any stock
             exchange or similar authority or organization; 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 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 Securities Exchange Act of 1934, as amended.

      This Power of Attorney shall remain in full force and effect until 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,
unless earlier revoked by the undersigned in 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 10th day of October 2018.



                                        /s/ Alfred J. Ford, Jr.
                                        ------------------------------
                                        Alfred J. Ford, Jr.