0000899243-18-028094.txt : 20181102
0000899243-18-028094.hdr.sgml : 20181102
20181102193553
ACCESSION NUMBER: 0000899243-18-028094
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: Wisniewski Raphael
CENTRAL INDEX KEY: 0001578307
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-38721
FILM NUMBER: 181158464
MAIL ADDRESS:
STREET 1: 120 MOUNTAIN VIEW BOULEVARD
CITY: BASKING RIDGE
STATE: NJ
ZIP: 07920
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
0001578307
Wisniewski Raphael
26 TECHNOLOGY DRIVE
IRVINE
CA
92618
1
0
1
0
Common Stock
2018-11-02
4
C
0
799228
A
799228
I
See footnote
Common Stock
2018-11-02
4
C
0
806080
A
1605308
I
See footnote
Common Stock
2018-11-02
4
C
0
431250
A
2036558
I
See footnote
Common Stock
2018-11-02
4
C
0
654237
A
2690795
I
See footnote
Common Stock
2018-11-02
4
P
0
866666
15.00
A
3557461
I
See footnote
Series A Preferred Stock
2018-11-02
4
C
0
345000
0.00
D
Common Stock
799228
0
I
See footnote
Series B-1 Preferred Stock
2018-11-02
4
C
0
671733
0.00
D
Common Stock
806080
0
I
See footnote
Series B-2 Preferred Stock
2018-11-02
4
C
0
359375
0.00
D
Common Stock
431250
0
I
See footnote
Series C Preferred Stock
2018-11-02
4
C
0
545197
0.00
D
Common Stock
654237
0
I
See footnote
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 A preferred stock automatically converted into 2.31660 shares of the Issuer's common stock. The A preferred stock had no expiration date.
2,824,128 shares are held of record by BioDiscovery 4 FCPR ("BioDiscovery") and 733,333 shares are held of record by BioDiscovery 5 ("BioDiscovery 5"). Andera Partners ("Andera") is the manager of BioDiscovery and BioDiscovery 5 and may be deemed to have sole voting and dispositive power over the shares held by BioDiscovery and BioDiscovery 5. The reporting person is a director of the Issuer and is a partner of Andera, and may be deemed to share voting and dispositive power over the shares held by BioDiscovery and BioDiscovery 5. The reporting person disclaims beneficial ownership of these securities except to the extent of his pecuniary interest therein, and the inclusion of these shares in this report shall not be deemed an admission of beneficial ownership of all of the reported shares for purposes of Section 16 or for any other purpose.
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 B-1 preferred stock automatically converted into 1.2 shares of the Issuer's common stock. The B-1 preferred stock had no expiration date.
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 B-2 preferred stock automatically converted into 1.2 shares of the Issuer's common stock. The B-2 preferred stock had no expiration date.
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 C preferred stock had no expiration date.
/s/ Michael V. Williamson, as Attorney-in-Fact for Raphael Wisniewski
2018-11-02