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