0001742429-22-000006.txt : 20220412 0001742429-22-000006.hdr.sgml : 20220412 20220412191720 ACCESSION NUMBER: 0001742429-22-000006 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20220410 FILED AS OF DATE: 20220412 DATE AS OF CHANGE: 20220412 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Chacon Quiros Juan Jose CENTRAL INDEX KEY: 0001742429 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38593 FILM NUMBER: 22823326 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: 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_164980542571828.xml FORM 4 X0306 4 2022-04-10 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 Common Shares 2022-04-10 4 A 0 10464 0 A 204704 D Common Shares 1128264 I See Footnote Stock Option (Right to buy) 63.53 2022-04-10 4 A 0 27524 0 A 2032-04-10 Common Shares 27524.0 27524 D Represents an award of stock units under the Issuer's 2018 Equity Incentive Plan. One-fourth of the shares subject to the award shall vest on April 10, 2023 and each one-year anniversary thereafter, subject to the Reporting Person continuing as a service provider through such 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. One-fourth of the shares subject to the option shall vest on April 10, 2023 and each one-year anniversary thereafter, subject to the Reporting Person continuing as a service provider through such date. /s/ Rajbir S. Denhoy, by power of attorney 2022-04-12