0001570562-19-000022.txt : 20190125 0001570562-19-000022.hdr.sgml : 20190125 20190125202018 ACCESSION NUMBER: 0001570562-19-000022 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20190123 FILED AS OF DATE: 20190125 DATE AS OF CHANGE: 20190125 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: BLANK SIMONE CENTRAL INDEX KEY: 0001366840 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38381 FILM NUMBER: 19543677 MAIL ADDRESS: STREET 1: C/O SIRONA, WASSERFELDSTRASSE 30 A-5020 CITY: SALZBURG STATE: C4 ZIP: 5020 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: Evolus, Inc. CENTRAL INDEX KEY: 0001570562 STANDARD INDUSTRIAL CLASSIFICATION: PHARMACEUTICAL PREPARATIONS [2834] IRS NUMBER: 461385614 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 520 NEWPORT CENTER DRIVE STREET 2: SUITE 1200 CITY: NEWPORT BEACH STATE: CA ZIP: 92660 BUSINESS PHONE: (949) 284-4555 MAIL ADDRESS: STREET 1: 520 NEWPORT CENTER DRIVE STREET 2: SUITE 1200 CITY: NEWPORT BEACH STATE: CA ZIP: 92660 4 1 wf-form4_154846560188517.xml FORM 4 X0306 4 2019-01-23 0 0001570562 Evolus, Inc. EOLS 0001366840 BLANK SIMONE 520 NEWPORT CENTER DR. SUITE 1200 NEWPORT BEACH CA 92660 1 0 0 0 Stock Option (Right to Buy) 16.19 2019-01-23 4 A 0 14500 0 A 2029-01-23 Common Stock 14500.0 14500 D The shares subject to the option will vest as to 1/12 of the underlying shares monthly from the vesting commencement date of January 23, 2019, provided the reporting person remains in continuous service on each vesting date, subject to accelerated vesting in certain events, including certain terminations of the reporting person or upon certain changes of control of the issuer. /s/ Jeffrey J. Plumer, as attorney-in-fact for Simone Blank 2019-01-25