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