0000899243-18-028083.txt : 20181102 0000899243-18-028083.hdr.sgml : 20181102 20181102192836 ACCESSION NUMBER: 0000899243-18-028083 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: Tammenoms Bakker Juliet CENTRAL INDEX KEY: 0001431159 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38721 FILM NUMBER: 181158447 MAIL ADDRESS: STREET 1: LONGITUDE CAPITAL MANAGEMENT CO., LLC STREET 2: 800 EL CAMINO REAL, SUITE 220 CITY: MENLO PARK STATE: CA ZIP: 94025 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 0001431159 Tammenoms Bakker Juliet 2740 SAND HILL RD 2ND FLOOR MENLO PARK CA 94025 1 0 1 0 Common Stock 2018-11-02 4 C 0 2400000 A 2400000 I By Longitude Venture Partners III, L.P. Common Stock 2018-11-02 4 P 0 533333 15.00 A 2933333 I By Longitude Venture Partners III, L.P. Series C Preferred Stock 2018-11-02 4 C 0 2000000 0.00 D Common Stock 2400000 0 I By Longitude Venture Partners III, L.P. 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 C preferred stock automatically converted into 1.2 shares of the Issuer's common stock. The Series C preferred stock had no expiration date. These shares are held directly by Longitude Venture Partners III, L.P. ("Longitude Venture III"). Longitude Capital Partners III, LLC ("Longitude Capital III"), is the general partner of Longitude Venture III and may be deemed to have voting, investment and dispositive power with respect to these securities. Ms. Tammenoms Bakker, who is a member of the Issuer's board of directors, and Patrick G. Enright are the managing members of Longitude Capital III (each a "Manager" and collectively, the "Managers"), and may each be deemed to share voting, investment and dispositive power with respect to these securities. Each of Longitude Capital III and the Managers 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/ Michael V. Williamson, as Attorney-in-Fact for Juliet Tammenoms Bakker 2018-11-02