0000899243-18-028086.txt : 20181102
0000899243-18-028086.hdr.sgml : 20181102
20181102193229
ACCESSION NUMBER: 0000899243-18-028086
CONFORMED SUBMISSION TYPE: 4
PUBLIC DOCUMENT COUNT: 1
CONFORMED PERIOD OF REPORT: 20181102
FILED AS OF DATE: 20181102
DATE AS OF CHANGE: 20181102
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: Petrovich John George
CENTRAL INDEX KEY: 0001387382
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-38721
FILM NUMBER: 181158454
MAIL ADDRESS:
STREET 1: CALANDO PHARMACEUTICALS INC.
STREET 2: 2585 NINA STREET
CITY: PASADENA
STATE: CA
ZIP: 91107
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
4
1
doc4.xml
FORM 4 SUBMISSION
X0306
4
2018-11-02
0
0001603756
Axonics Modulation Technologies, Inc.
AXNX
0001387382
Petrovich John George
26 TECHNOLOGY DRIVE
IRVINE
CA
92618
1
0
0
1
Former 10% Owner
Common Stock
2018-11-02
4
C
0
289576
A
1177576
I
See footnote
Common Stock
2018-11-02
4
C
0
925394
A
2102970
I
See footnote
Series A Preferred Stock
2018-11-02
4
C
0
125000
0.00
D
Common Stock
289576
0
I
See footnote
Series B-1 Preferred Stock
2018-11-02
4
C
0
771161
0.00
D
Common Stock
925394
0
I
See footnote
Reflects a 1.2-for-1 forward stock split of the Issuer's common stock effected on October 18, 2018.
Effective upon the closing of the Issuer's initial public offering of its common stock under the Securities Act of 1933, as amended, each share of Series A preferred stock automatically converted into 2.31660 shares of the Issuer's common stock. The A preferred stock had no expiration date.
These securities are held by The Alfred E. Mann Foundation for Scientific Research. The reporting person disclaims beneficial ownership of these securities, and this report shall not be deemed an admission that the reporting person is the beneficial owner of the securities for purposes of Section 16 or for any other purpose.
Effective upon the closing of the Issuer's initial public offering of its common stock under the Securities Act of 1933, as amended, each share of Series B-1 preferred stock automatically converted into 1.2 shares of the Issuer's common stock. The B-1 preferred stock had no expiration date.
/s/ Michael V. Williamson, as Attorney-in-Fact for John George Petrovich
2018-11-02