0001628280-18-009512.txt : 20180723
0001628280-18-009512.hdr.sgml : 20180723
20180723162853
ACCESSION NUMBER: 0001628280-18-009512
CONFORMED SUBMISSION TYPE: 4
PUBLIC DOCUMENT COUNT: 1
CONFORMED PERIOD OF REPORT: 20180723
FILED AS OF DATE: 20180723
DATE AS OF CHANGE: 20180723
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: LEWIN NICHOLAS SHERIDAN
CENTRAL INDEX KEY: 0001398327
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-38593
FILM NUMBER: 18964708
MAIL ADDRESS:
STREET 1: 3 WEST 57TH ST.
STREET 2: 8TH FLOOR
CITY: NEW YORK
STATE: NY
ZIP: 10019
ISSUER:
COMPANY DATA:
COMPANY CONFORMED NAME: ESTABLISHMENT LABS HOLDINGS INC.
CENTRAL INDEX KEY: 0001688757
STANDARD INDUSTRIAL CLASSIFICATION: ORTHOPEDIC, PROSTHETIC & SURGICAL APPLIANCES & SUPPLIES [3842]
IRS NUMBER: 000000000
STATE OF INCORPORATION: D8
BUSINESS ADDRESS:
STREET 1: PO BOX 3140, COMMERCE HOUSE
STREET 2: WICKHAMS CAY 1, ROAD TOWN
CITY: TORTOLA
STATE: D8
ZIP: VG1110
BUSINESS PHONE: 50624342400
MAIL ADDRESS:
STREET 1: PO BOX 3140, COMMERCE HOUSE
STREET 2: WICKHAMS CAY 1, ROAD TOWN
CITY: TORTOLA
STATE: D8
ZIP: VG1110
4
1
wf-form4_153237771553912.xml
FORM 4
X0306
4
2018-07-23
0
0001688757
ESTABLISHMENT LABS HOLDINGS INC.
ESTA
0001398327
LEWIN NICHOLAS SHERIDAN
C/O MOTIVA USA LLC
16192 COASTAL HIGHWAY
LEWES
DE
19958
1
0
1
0
Common Shares
2018-07-23
4
C
0
7516131
A
7516131
I
See Footnote
Class B Ordinary Shares
2018-07-23
4
C
0
7516131
0
D
Common Shares
7516131.0
0
I
See Footnote
The Class B Ordinary Shares automatically converted into Common Shares on a one-for-one basis upon the closing of the Issuer's initial public offering of Common Shares and had no expiration date.
The shares are held by CPH TU, LP, of which the Reporting Person is a managing partner. The Reporting Person disclaims beneficial ownership of the shares held by CPH TU, LP, except to the extent of his pecuniary interest therein.
/s/ Renee Gaeta, by power of attorney
2018-07-23