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