0001562180-23-005113.txt : 20230613
0001562180-23-005113.hdr.sgml : 20230613
20230613163004
ACCESSION NUMBER: 0001562180-23-005113
CONFORMED SUBMISSION TYPE: 4
PUBLIC DOCUMENT COUNT: 2
CONFORMED PERIOD OF REPORT: 20230609
FILED AS OF DATE: 20230613
DATE AS OF CHANGE: 20230613
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: Nishimura Mika
CENTRAL INDEX KEY: 0001848327
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-38701
FILM NUMBER: 231011546
MAIL ADDRESS:
STREET 1: 471 EL CAMINO REAL
CITY: SANTA CLARA
STATE: CA
ZIP: 95050
ISSUER:
COMPANY DATA:
COMPANY CONFORMED NAME: SI-BONE, Inc.
CENTRAL INDEX KEY: 0001459839
STANDARD INDUSTRIAL CLASSIFICATION: SURGICAL & MEDICAL INSTRUMENTS & APPARATUS [3841]
IRS NUMBER: 262216351
STATE OF INCORPORATION: DE
FISCAL YEAR END: 1231
BUSINESS ADDRESS:
STREET 1: 471 EL CAMINO REAL, SUITE 101
CITY: SANTA CLARA
STATE: CA
ZIP: 95050
BUSINESS PHONE: 4082070700
MAIL ADDRESS:
STREET 1: 471 EL CAMINO REAL, SUITE 101
CITY: SANTA CLARA
STATE: CA
ZIP: 95050
FORMER COMPANY:
FORMER CONFORMED NAME: SI-Bone Inc.
DATE OF NAME CHANGE: 20090326
4
1
primarydocument.xml
PRIMARY DOCUMENT
X0407
4
2023-06-09
false
0001459839
SI-BONE, Inc.
SIBN
0001848327
Nishimura Mika
C/O SI-BONE, INC.
471 EL CAMINO REAL, SUITE 101
SANTA CLARA
CA
95050
true
false
false
false
false
Common Stock
2023-06-09
4
A
false
4866.00
0.00
A
21850.00
D
Reflects shares issuable on the settlement of restricted stock units granted to the Reporting Person. Each restricted stock unit represents a contingent right to receive one share of the Issuer's common stock. The shares subject to the restricted stock unit will vest 100% upon the earlier of (i) the next annual general meeting of the stockholders of the Company or (ii) the date one year from the Vesting Commencement Date, subject to the Reporting Person's continuous service as a member of the Company's Board of Directors until such date.
Includes 4,866 shares issuable on the settlement of restricted stock units granted to the Reporting Person. Each restricted stock unit
represents a contingent right to receive one share of the Issuer's common stock.
/s/ Michael Pisetsky, Attorney-in-Fact for Mika Nishimura
2023-06-13
EX-24
2
mikanishimurapoa2021.txt
POWER OF ATTORNEY 2021 M NISHIMURA
POWER OF ATTORNEY
Know all by these presents, that the undersigned hereby constitutes and
appoints each of LAURA A. FRANCIS, MICHAEL A. PISETSKY, MATTHEW B. HEMINGTON
and KRIS TAMASHIRO, signing individually, the undersigned's true and lawful
attorneys-in-fact and agents to:
(1) execute for and on behalf of the undersigned, in the undersigned's capacity
as an officer, director or beneficial owner of more than 10% of a registered
class of securities of SI-BONE, INC. (the "Company"), Forms 3, 4 and 5
(including any amendments thereto) in accordance with Section 16(a) of the
Securities Exchange Act of 1934, as amended (the "Exchange Act") and the rules
thereunder and a Form ID, Uniform Application for Access Codes to File on EDGAR;
(2) do and perform any and all acts for and on behalf of the undersigned that
may be necessary or desirable to execute such Forms 3, 4 or 5 or Form ID
(including any amendments thereto) and timely file such forms with the United
States Securities and Exchange Commission and any stock exchange or similar
authority; and
(3) take any other action of any nature whatsoever in connection with the
foregoing which, in the opinion of such attorney-in-fact, may be of benefit, in
the best interest of, or legally required by, the undersigned, it being
understood that the documents executed by such attorney-in-fact on behalf of the
undersigned pursuant to this Power of Attorney shall be in such form and shall
contain such terms and conditions as such attorney-in-fact may approve in such
attorney-in-fact's discretion.
The undersigned hereby grants to each such attorney-in-fact full power and
authority to do and perform any and every act and thing whatsoever requisite,
necessary or proper to be done in the exercise of any of the rights and powers
herein granted, as fully to all intents and purposes as the undersigned might or
could do if personally present, with full power of substitution or revocation,
hereby ratifying and confirming all that such attorney-in-fact, or such attorney
-in-fact's substitute or substitutes, shall lawfully do or cause to be done by
virtue of this power of attorney and the rights and powers herein granted. The
undersigned acknowledges that the foregoing attorneys-in-fact, in serving in
such capacity at the request of the undersigned, are not assuming, nor is the
Company assuming, any of the undersigned's responsibilities to comply with
Section 16 of the Exchange Act.
This Power of Attorney shall remain in full force and effect until the earliest
to occur of (a) the undersigned is no longer required to file Forms 3, 4 and 5
with respect to the undersigned's holdings of and transactions in securities
issued by the Company, (b) revocation by the undersigned in a signed writing
delivered to the foregoing attorneys-in-fact or (c) as to any attorney-in-fact
individually, until such attorney-in-fact is no longer employed by the Company
or Cooley LLP.
IN WITNESS WHEREOF, the undersigned has caused this Power of Attorney to be
executed as of February 23, 2021.
/s/ Mika Nishimura
Mika Nishimura