0000899243-18-028099.txt : 20181102
0000899243-18-028099.hdr.sgml : 20181102
20181102194023
ACCESSION NUMBER: 0000899243-18-028099
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: Amble Erik
CENTRAL INDEX KEY: 0001756337
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-38721
FILM NUMBER: 181158471
MAIL ADDRESS:
STREET 1: 26 TECHNOLOGY DRIVE
CITY: IRVINE
STATE: CA
ZIP: 92618
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
0001756337
Amble Erik
26 TECHNOLOGY DRIVE
IRVINE
CA
92618
1
0
0
1
Former 10% Owner
Common Stock
2018-11-02
4
C
0
451738
A
451738
I
By NeoMed Innovation V, L.P.
Common Stock
2018-11-02
4
C
0
455610
A
907348
I
By NeoMed Innovation V, L.P.
Common Stock
2018-11-02
4
C
0
243750
A
1151098
I
By NeoMed Innovation V, L.P.
Common Stock
2018-11-02
4
C
0
369786
A
1520884
I
By NeoMed Innovation V, L.P.
Series A Preferred Stock
2018-11-02
4
C
0
195000
0.00
D
Common Stock
451738
0
I
By NeoMed Innovation V, L.P.
Series B-1 Preferred Stock
2018-11-02
4
C
0
379675
0.00
D
Common Stock
455610
0
I
By NeoMed Innovation V, L.P.
Series B-2 Preferred Stock
2018-11-02
4
C
0
203125
0.00
D
Common Stock
243750
0
I
By NeoMed Innovation V, L.P.
Series C Preferred Stock
2018-11-02
4
C
0
308155
0.00
D
Common Stock
369786
0
I
By NeoMed Innovation V, 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 A preferred stock automatically converted into 2.31660 shares of the Issuer's common stock. The A preferred stock had no expiration date.
The shares are held of record by NeoMed Innovation V, L.P. ("NeoMed"). NeoMed Innovation V Limited is the general partner of NeoMed and has voting and dispositive power over the shares held by NeoMed. Erik Amble, Ph.D., who is a member of the Issuer's board of directors, is a director of NeoMed Innovation V Limited, and may be deemed to have voting and dispositive power over the shares held by NeoMed. Mr. Amble disclaims beneficial ownership of these securities and this report shall not be deemed an admission that Mr. Amble is the beneficial owner of such securities for purposes of Section 16 or for any other purpose, except to the extent of his respective pecuniary interest therein.
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 Erik Amble, Ph.D.
2018-11-02