0001628280-21-024863.txt : 20211210 0001628280-21-024863.hdr.sgml : 20211210 20211210163916 ACCESSION NUMBER: 0001628280-21-024863 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 2 CONFORMED PERIOD OF REPORT: 20211208 FILED AS OF DATE: 20211210 DATE AS OF CHANGE: 20211210 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Custin Ann CENTRAL INDEX KEY: 0001863404 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38593 FILM NUMBER: 211485887 MAIL ADDRESS: STREET 1: C/O MOTIVA USA, LLC STREET 2: 16192 COASTAL HIGHWAY CITY: LEWES STATE: DE ZIP: 19958 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: 981436377 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 4 1 wf-form4_163917233350491.xml FORM 4 X0306 4 2021-12-08 0 0001688757 ESTABLISHMENT LABS HOLDINGS INC. ESTA 0001863404 Custin Ann C/O MOTIVA USA LLC 16192 COASTAL HIGHWAY LEWES DE 19958 1 0 0 0 Stock Option (Right to buy) 69.05 2021-12-08 4 A 0 12000 0 A 2031-12-08 Common Shares 12000.0 12000 D As disclosed on a Form 4 filed with the Securities and Exchange Commission on July 15, 2021, the Reporting Person was previously granted an option to purchase common shares of the Issuer. The Issuer subsequently determined that the foregoing grant did not comply with the terms of the equity incentive plan under which it was granted and is void and of no force and effect. On December 8, 2021, the Reporting Person was granted the new stock option reported herein. One-third of the shares subject to the option shall vest on July 13, 2022 and each one-year anniversary thereafter, subject to the Reporting Person continuing as a service provider through each such date. /s/ Rajbir S. Denhoy, by power of attorney 2021-12-10 EX-24 2 establishmentlabspoaanncus.htm ESTABLISHMENT LABS POA ANN CUSTIN

POWER OF ATTORNEY

The undersigned, as a Section 16 reporting person of Establishment Labs, Inc.
(the "Company"), hereby constitutes and appoints each of Juan Jose Chacon Quiros and Renee Gaeta, 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 8th day of July, 2021.


/s/ Ann Custin
Signature