0000899243-18-028112.txt : 20181102 0000899243-18-028112.hdr.sgml : 20181102 20181102195455 ACCESSION NUMBER: 0000899243-18-028112 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: Pardo Geoff CENTRAL INDEX KEY: 0001756338 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38721 FILM NUMBER: 181158500 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 0001756338 Pardo Geoff 26 TECHNOLOGY DRIVE IRVINE CA 92618 1 0 1 0 Common Stock 2018-11-02 4 C 0 2266666 A 2266666 I By Cooperatieve Gilde Healthcare IV U.A. Common Stock 2018-11-02 4 P 0 866666 15.00 A 3133332 I By Cooperatieve Gilde Healthcare IV U.A. Series C Preferred Stock 2018-11-02 4 C 0 1888888 0.00 D Common Stock 2266666 0 I By Cooperatieve Gilde Healthcare IV U.A. 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. The shares are held directly by Cooperatieve Gilde Healthcare IV U.A. ("Gilde"). The reporting person, who is a member of the Issuer's board of directors, is a partner of Gilde. Gilde is managed by Gilde Healthcare IV Management B.V. ("Management"). Management is owned by Gilde Healthcare Holding B.V. ("Holding"). Each of the reporting person, Management and Holding may be deemed to have voting, investment and dispositive power with respect to these securities. Each of the reporting person, Management and Holding 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 Geoff Pardo 2018-11-02