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