0001516513-21-000042.txt : 20211208
0001516513-21-000042.hdr.sgml : 20211208
20211208170045
ACCESSION NUMBER: 0001516513-21-000042
CONFORMED SUBMISSION TYPE: 4
PUBLIC DOCUMENT COUNT: 1
CONFORMED PERIOD OF REPORT: 20211207
FILED AS OF DATE: 20211208
DATE AS OF CHANGE: 20211208
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: Tangney Jeffrey
CENTRAL INDEX KEY: 0001863328
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-40508
FILM NUMBER: 211479363
MAIL ADDRESS:
STREET 1: C/O DOXIMITY, INC.
STREET 2: 500 3RD STREET SUITE 510
CITY: SAN FRANCISCO
STATE: CA
ZIP: 94107
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: Tangney Schweikert Family Trust
CENTRAL INDEX KEY: 0001868242
STATE OF INCORPORATION: CA
FISCAL YEAR END: 1231
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-40508
FILM NUMBER: 211479362
BUSINESS ADDRESS:
STREET 1: C/O DOXIMITY, INC.
STREET 2: 500 3RD STREET, SUITE 510
CITY: SAN FRANCISCO
STATE: CA
ZIP: 94107
BUSINESS PHONE: 650-549-4330
MAIL ADDRESS:
STREET 1: C/O DOXIMITY, INC.
STREET 2: 500 3RD STREET, SUITE 510
CITY: SAN FRANCISCO
STATE: CA
ZIP: 94107
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: Tangney Annuity Trust, LLC
CENTRAL INDEX KEY: 0001867907
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-40508
FILM NUMBER: 211479361
BUSINESS ADDRESS:
STREET 1: C/O DOXIMITY, INC.
STREET 2: 500 3RD STREET, SUITE 510
CITY: SAN FRANCISCO
STATE: CA
ZIP: 94107
BUSINESS PHONE: 650-549-4330
MAIL ADDRESS:
STREET 1: C/O DOXIMITY, INC.
STREET 2: 500 3RD STREET, SUITE 510
CITY: SAN FRANCISCO
STATE: CA
ZIP: 94107
ISSUER:
COMPANY DATA:
COMPANY CONFORMED NAME: Doximity, Inc.
CENTRAL INDEX KEY: 0001516513
STANDARD INDUSTRIAL CLASSIFICATION: SERVICES-COMPUTER PROGRAMMING SERVICES [7371]
IRS NUMBER: 272485512
STATE OF INCORPORATION: DE
FISCAL YEAR END: 0331
BUSINESS ADDRESS:
STREET 1: 500 THIRD STREET
CITY: SAN FRANCISCO
STATE: CA
ZIP: 94107
BUSINESS PHONE: (650) 549-4330
MAIL ADDRESS:
STREET 1: 500 THIRD STREET
CITY: SAN FRANCISCO
STATE: CA
ZIP: 94107
4
1
wf-form4_163900082992869.xml
FORM 4
X0306
4
2021-12-07
0
0001516513
Doximity, Inc.
DOCS
0001863328
Tangney Jeffrey
DOXIMITY, INC.
500 THIRD STREET
SAN FRANCISCO
CA
94107
1
1
1
0
Chief Executive Officer
0001868242
Tangney Schweikert Family Trust
C/O DOXIMITY, INC.
500 THIRD STREET
SAN FRANCISCO
CA
94107
0
0
1
0
0001867907
Tangney Annuity Trust, LLC
C/O DOXIMITY, INC.
500 THIRD STREET
SAN FRANCISCO
CA
94107
0
0
1
0
Class A Common Stock
2021-12-07
4
C
0
150000
A
250000
D
Class A Common Stock
150000
I
By Tangney Schweikert Family Trust
Class B Common Stock
2021-12-07
4
C
0
150000
0
D
Class A Common Stock
150000.0
6171666
D
Class B Common Stock
Class A Common Stock
24203330.0
24203330
I
By Tangney Schweikert Family Trust
Class B Common Stock
Class A Common Stock
20000000.0
20000000
I
By Tangney Annuity Trust, LLC
Each share of Class B Common Stock, par value $0.001 per share (the "Class B Common Stock"), converted into one share of Class A Common Stock, par value $0.001 per share (the "Class A Common Stock"), at the option of the holder.
These shares are owned directly by Jeffrey Tangney.
These shares are owned directly by the Tangney Schweikert Family Trust, a ten percent owner of the Issuer, and indirectly by Mr. Tangney as trustee of such trust. Mr. Tangney is an officer, director and ten percent owner of the Issuer.
Each share of Class B Common Stock is convertible into one share of Class A Common Stock at any time at the option of the holder. Each share of Class B Common Stock held by the Reporting Person will automatically convert into one share of Class A Common Stock, upon the following: (1) the sale or transfer of such share of Class B Common Stock, except for certain permitted transfers described in the Issuer's amended and restated certificate of incorporation; (2) the death or incapacity of the Reporting Person; and (3) on the final conversion date, defined as the earlier of (a) the tenth anniversary of the effectiveness of the registration statement in connection with the Issuer's initial public offering; or (b) the date specified by a vote of the holders of at least 66 2/3% of the outstanding shares of Class B Common Stock, voting as a single class.
These shares are owned directly by Tangney Annuity Trust, LLC, a ten percent owner of the Issuer, and indirectly by Mr. Tangney as trustee of such trust.
/s/ Jennifer Chaloemtiarana, Attorney-in-Fact for Jeffrey Tangney
2021-12-08
/s/ Jennifer Chaloemtiarana, Attorney-in-Fact for Tangney Schweikert Family Trust
2021-12-08
/s/ Jennifer Chaloemtiarana, Attorney-in-Fact for Tangney Annuity Trust, LLC
2021-12-08