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