0001628280-18-009330.txt : 20180718 0001628280-18-009330.hdr.sgml : 20180718 20180718174004 ACCESSION NUMBER: 0001628280-18-009330 CONFORMED SUBMISSION TYPE: 3 PUBLIC DOCUMENT COUNT: 2 CONFORMED PERIOD OF REPORT: 20180718 FILED AS OF DATE: 20180718 DATE AS OF CHANGE: 20180718 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Chacon Quiros Juan Jose CENTRAL INDEX KEY: 0001742429 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38593 FILM NUMBER: 18959116 MAIL ADDRESS: STREET 1: C/O MOTIVA USA LLC STREET 2: 16192 COASTAL HIGHWAY CITY: LEWES STATE: DE ZIP: 19958 FORMER NAME: FORMER CONFORMED NAME: Quiros Juan Jose Chacon DATE OF NAME CHANGE: 20180601 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: ESTABLISHMENT LABS HOLDINGS INC. CENTRAL INDEX KEY: 0001688757 STANDARD INDUSTRIAL CLASSIFICATION: ORTHOPEDIC, PROSTHETIC & SURGICAL APPLIANCES & SUPPLIES [3842] IRS NUMBER: 000000000 STATE OF INCORPORATION: D8 BUSINESS ADDRESS: STREET 1: PO BOX 3140, COMMERCE HOUSE STREET 2: WICKHAMS CAY 1, ROAD TOWN CITY: TORTOLA STATE: D8 ZIP: VG1110 BUSINESS PHONE: 50624342400 MAIL ADDRESS: STREET 1: PO BOX 3140, COMMERCE HOUSE STREET 2: WICKHAMS CAY 1, ROAD TOWN CITY: TORTOLA STATE: D8 ZIP: VG1110 3 1 wf-form3_153194998830594.xml FORM 3 X0206 3 2018-07-18 0 0001688757 ESTABLISHMENT LABS HOLDINGS INC. ESTA 0001742429 Chacon Quiros Juan Jose C/O MOTIVA USA LLC 16192 COASTAL HIGHWAY LEWES DE 19958 1 1 0 0 Chief Executive Officer Class A Ordinary Shares Common Shares 237026.0 D Class A Ordinary Shares Common Shares 1128264.0 I See Footnote Restricted Stock Award 0.0 2019-09-09 Class A Ordinary Shares 57214.0 D Each Class A Ordinary Share shall automatically convert into Common Shares on a one-for-one basis upon the closing of the Issuer's initial public offering of Common Shares and has no expiration date. The shares are held by Sariel LLC. The Reporting Person is a shareholder of Sariel LLC and has voting and dispositive power over the shares owned by Sariel LLC. The Reporting Person disclaims beneficial ownership of the shares held by Sariel LLC, except to the extent of his pecuniary interest therein. The award, originally granted for 294,240 shares, of which 237,026 shares have been released, vested as to one half of the shares on September 9, 2016 and as to 1/72nd of the shares each month thereafter, subject to the Reporting Person continuing as a service provider through each such date. Exhibit 24 - Power of Attorney /s/ Renee Gaeta, by power of attorney 2018-07-18 EX-24 2 ex-24.htm ESTABLISHMENT LABS POA JUAN JOSE CHACON

POWER OF ATTORNEY

The undersigned, as a Section 16 reporting person of Establishment Labs, Inc.
(the "Company"), hereby constitutes and appoints Juan Jose Chacon Quiros and Renee Gaeta and each of them, the undersigned's true and lawful attorney-in-fact, to:

1.    Prepare, execute in the undersigned's name and on the undersigned's behalf, and submit to the Securities and Exchange Commission (the "SEC") a Form ID, including amendments thereto, and any other documents necessary or appropriate to obtain EDGAR codes and passwords enabling the undersigned to make electronic filings with the SEC of reports required by Section 16(a) of the Securities Exchange Act of 1934 or any rule or regulation of the SEC;

2.    Complete and execute Forms 3, 4 and 5 and other forms and all amendments thereto as such attorney-in-fact shall in his or her discretion determine to be required or advisable pursuant to Section 16 of the Securities Exchange Act of 1934 (as amended) and the rules and regulations promulgated thereunder, or any successor laws and regulations, as a consequence of the undersigned's ownership, acquisition or disposition of securities of the Company; and

3.    Do all acts necessary in order to file such forms with the SEC, any securities exchange or national association, the Company and such other person or agency as the attorney-in-fact shall deem appropriate.

The undersigned hereby ratifies and confirms all that said attorneys in-fact and agent shall do or cause to be done by virtue hereof.  The undersigned acknowledges that the foregoing attorneys-in-fact, in serving in such capacity at the request of the undersigned, are not assuming, nor is the Company assuming, any of the undersigned's responsibilities to comply with Section 16 of the Securities Exchange Act of 1934 (as amended).

This Power of Attorney shall remain in full force and effect until the undersigned is no longer required to file Forms ID, 3, 4 and 5 with respect to the undersigned's holdings of and transactions in securities issued by the Company, unless earlier revoked by the undersigned in a signed writing delivered to the Company and the foregoing attorneys-in-fact.

IN WITNESS WHEREOF, the undersigned has caused this Power of Attorney to be executed as of this 23rd day of April, 2018.

Juan Jose Chacon Quiros


/s/ Juan Jose Chacon Quiros
Signature

STATE OF NEW YORK        )
COUNTY OF NEW YORK        )

On April 23, 2018, before me, _________________________________, personally appeared Juan Jose Chacon Quiros, who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.

I certify under PENALTY OF PERJURY under the laws of the State of New York that the foregoing paragraph is true and correct.

WITNESS my hand and official seal.

Signature: /s/ Vanessa Goodman
    Notary Public

Vanessa Goodman
Notary Public State of New York
No. 01GO488218
Qualified in Queens County
Certificate filed in New York County
Commission Expires May 4, 2019                                 (Seal)