UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934, Section 17(a) of the Public Utility Holding Company Act of 1935 or Section 30(h) of the Investment Company Act of 1940 |
|
| ||||||||||||||||||||||||||||||
|
Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | SEC 1473 (7-02) | ||
Persons who respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB control number. |
1. Title of Derivative Security (Instr. 4) |
2. Date Exercisable and Expiration Date (Month/Day/Year) |
3. Title and Amount of Securities Underlying Derivative Security (Instr. 4) |
4. Conversion or Exercise Price of Derivative Security | 5. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 5) |
6. Nature of Indirect Beneficial Ownership (Instr. 5) |
||
Date Exercisable | Expiration Date | Title | Amount or Number of Shares | ||||
Series C Convertible Participating Preferred Stock | Â (1) | Â (2) | Common Stock | 972,384 (1) (3) | $ (1) | D | Â |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
EXCEL MEDICAL FUND LP 800 BOYLSTON ST. SUITE 2825 BOSTON, MA 02199 |
 |  X |  |  |
Blume Frederick R. 800 BOYLSTON ST. SUITE 2825 BOSTON, MA 02199 |
 |  X |  |  |
Enriquez Juan 800 BOYLSTON ST. SUITE 2825 BOSTON, MA 02199 |
 |  X |  |  |
Petrillo Enrico 800 BOYLSTON ST. SUITE 2825 BOSTON, MA 02199 |
 |  X |  |  |
Excel Medical Ventures, LLC 800 BOYLSTON ST. SUITE 2825 BOSTON, MA 02199 |
 |  X |  |  |
Excel Medial Fund L.P. By: Excel Medical Ventures, LLC its general partner By: /s/ Steven R. Gullans, Managing Director | 03/19/2013 | |
**Signature of Reporting Person | Date | |
/s/ Frederick R. Blume | 03/19/2013 | |
**Signature of Reporting Person | Date | |
/s/ Juan Enriquez | 03/19/2013 | |
**Signature of Reporting Person | Date | |
/s/ Enrico Petrillo, M.D. | 03/19/2013 | |
**Signature of Reporting Person | Date | |
Excel Medical Ventures, LLC by: /s/ Steven R. Gullans, its Managing Director | 03/19/2013 | |
**Signature of Reporting Person | Date |
* | If the form is filed by more than one reporting person, see Instruction 5(b)(v). |
** | Intentional misstatements or omissions of facts constitute Federal Criminal Violations. See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). |
(1) | Convertible into Common Stock on a 1-for-29 basis without payment of further consideration. Each share will automatically convert into 1/29th of a share of Common Stock upon the closing of the Issuer's initial public offering. |
(2) | Not Applicable |
(3) | Excel Medical Ventures, LLC is the general partner of Excel Medical Fund, L.P. Steven R. Gullans, Frederick R. Blume, Juan Enriquez and Enrico Petrillo are the Managing Directors of Excel Medical Ventures, LLC. Excel Medical Ventures, LLC and each of these individuals may be deemed to share voting and dispositive power with respect to all shares held by Excel Medical Fund, L.P. Each of the filing persons disclaims beneficial ownership of the shares except to the extent of any pecuniary interest therein. |