0000899243-18-027863.txt : 20181031 0000899243-18-027863.hdr.sgml : 20181031 20181031201035 ACCESSION NUMBER: 0000899243-18-027863 CONFORMED SUBMISSION TYPE: 3 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20181030 FILED AS OF DATE: 20181031 DATE AS OF CHANGE: 20181031 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Gilde Healthcare Holding B.V. CENTRAL INDEX KEY: 0001420106 STATE OF INCORPORATION: P7 FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38721 FILM NUMBER: 181151662 BUSINESS ADDRESS: STREET 1: NEWTONLAAN 91 STREET 2: PO BOX 85067 CITY: 3508 UTRECHT STATE: P7 ZIP: AB BUSINESS PHONE: 31(0)30-2192549 MAIL ADDRESS: STREET 1: NEWTONLAAN 91 STREET 2: PO BOX 85067 CITY: 3508 UTRECHT STATE: P7 ZIP: AB REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Gilde Healthcare IV Management B.V. CENTRAL INDEX KEY: 0001757508 STATE OF INCORPORATION: P7 FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38721 FILM NUMBER: 181151663 BUSINESS ADDRESS: STREET 1: NEWTONLAAN 91 CITY: UTRECHT STATE: P7 ZIP: 3584 BP BUSINESS PHONE: 949-396-6322 MAIL ADDRESS: STREET 1: NEWTONLAAN 91 CITY: UTRECHT STATE: P7 ZIP: 3584 BP REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Cooperatieve Gilde Healthcare IV U.A. CENTRAL INDEX KEY: 0001756335 STATE OF INCORPORATION: P7 FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38721 FILM NUMBER: 181151664 BUSINESS ADDRESS: STREET 1: NEWTONLANN 51 CITY: UTRECHT STATE: P7 ZIP: 3508AB BUSINESS PHONE: 949-396-6322 MAIL ADDRESS: STREET 1: NEWTONLANN 51 CITY: UTRECHT STATE: P7 ZIP: 3508AB 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 3 1 doc3.xml FORM 3 SUBMISSION X0206 3 2018-10-30 0 0001603756 Axonics Modulation Technologies, Inc. AXNX 0001420106 Gilde Healthcare Holding B.V. NEWTONLAAN 91 3584 BP UTRECHT THE NETHERLANDS 0 0 1 0 0001757508 Gilde Healthcare IV Management B.V. NEWTONLAAN 91 3584 BP UTRECHT THE NETHERLANDS 0 0 1 0 0001756335 Cooperatieve Gilde Healthcare IV U.A. NEWTONLAAN 91 3584 BP UTRECHT THE NETHERLANDS 0 0 1 0 Series C Preferred Stock Common Stock 2266666 I By Cooperatieve Gilde Healthcare IV U.A. Each share of Series C preferred stock is convertible, at any time, at the reporting person's election, into shares of the Issuer's common stock at the then-effective conversion rate for no additional consideration in accordance with the Issuer's Fourth Amended and Restated Certificate of Incorporation, as amended to date. In addition, 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 the Series C preferred stock will automatically convert into 1.2 shares of the Issuer's common stock. The Series C preferred stock has no expiration date. Reflects a 1.2-for-1 forward stock split of the Issuer's common stock effected on October 18, 2018. The shares are held directly by Cooperatieve Gilde Healthcare IV U.A. ("Gilde"). Geoff Pardo ("Pardo"), who is a member of the Issuer's board of directors, is a partner of Gilde. Gilde is managed by Gilde Healthcare IV Management B.V. ("Management"). Management is owned by Gilde Healthcare Holding B.V. ("Holding"). Each of Pardo, Management and Holding may be deemed to have voting, investment and dispositive power with respect to these securities. Each of Pardo, Management and Holding disclaims beneficial ownership of these securities and this report shall not be deemed an admission that any of them is the beneficial owner of such securities for purposes of Section 16 or for any other purpose, except to the extent of their respective pecuniary interests therein. /s/ Marc Perret, on behalf on Gilde Healthcare Holding B.V. 2018-10-30 /s/ Marc Perret, on behalf of Gilde Healthcare IV Management B.V. 2018-10-30 /s/ Marc Perret, on behalf of Cooperatieve Gilde Healthcare IV U.A. 2018-10-30