0001603756-17-000001.txt : 20170512 0001603756-17-000001.hdr.sgml : 20170512 20170511174533 ACCESSION NUMBER: 0001603756-17-000001 CONFORMED SUBMISSION TYPE: D PUBLIC DOCUMENT COUNT: 1 ITEM INFORMATION: 06b FILED AS OF DATE: 20170512 DATE AS OF CHANGE: 20170511 EFFECTIVENESS DATE: 20170512 FILER: COMPANY DATA: COMPANY CONFORMED NAME: Axonics Modulation Technologies, Inc. CENTRAL INDEX KEY: 0001603756 IRS NUMBER: 454744083 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: D SEC ACT: 1933 Act SEC FILE NUMBER: 021-286592 FILM NUMBER: 17835638 BUSINESS ADDRESS: STREET 1: 7575 IRVINE CENTER DRIVE, SUITE 200 CITY: IRVINE STATE: CA ZIP: 92618 BUSINESS PHONE: 949-396-6322 MAIL ADDRESS: STREET 1: 7575 IRVINE CENTER DRIVE, SUITE 200 CITY: IRVINE STATE: CA ZIP: 92618 D 1 primary_doc.xml X0707 D LIVE 0001603756 Axonics Modulation Technologies, Inc. 7575 IRVINE CENTER DRIVE, SUITE 200 IRVINE CA CALIFORNIA 92618 949-396-6322 DELAWARE None None Corporation true 2012 Raymond W. Cohen 7575 Irvine Center Drive, Suite 200 Irvine CA CALIFORNIA 92618 Executive Officer Director Dan L. Dearen 7575 Irvine Center Drive, Suite 200 Irvine CA CALIFORNIA 92618 Executive Officer Michael Williamson 7575 Irvine Center Drive, Suite 200 Irvine CA CALIFORNIA 92618 Executive Officer Raphael Wisniewski 7575 Irvine Center Drive, Suite 200 Irvine CA CALIFORNIA 92618 Director John Petrovich 7575 Irvine Center Drive, Suite 200 Irvine CA CALIFORNIA 92618 Director Darren Cai 7575 Irvine Center Drive, Suite 200 Irvine CA CALIFORNIA 92618 Director Erik Amble 7575 Irvine Center Drive, Suite 200 Irvine CA CALIFORNIA 92618 Director Shahzad Malik 7575 Irvine Center Drive, Suite 200 Irvine CA CALIFORNIA 92618 Director Farah Boroomand 7575 Irvine Center Drive, Suite 200 Irvine CA CALIFORNIA 92618 Director Other Technology Decline to Disclose 06b false 2017-04-28 false true false 0 35000000 14456295 20543705 false 11 0 0 0 false Axonics Modulation Technologies, Inc. /s/Raymond W. Cohen Raymond W. Cohen Chief Executive Officer 2017-05-11