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 |
Stock Option (right to buy)
|
Â
(1)
|
09/24/2017 |
Common Stock
|
15,000
|
$
7.2
|
D
|
Â
|
Stock Option (right to buy)
|
Â
(1)
|
09/24/2017 |
Common Stock
|
7.5
|
$
7.2
|
D
|
Â
|
Series C Convertible Preferred Stock
|
Â
(2)
|
Â
(2)
|
Common Stock
|
857,143
|
$
(2)
|
I
|
See footnotes
(3)
(6)
|
Series D Convertible Preferred Stock
|
Â
(4)
|
Â
(4)
|
Common Stock
|
199,732
|
$
(4)
|
I
|
See footnotes
(3)
(6)
|
Mandatorily Convertible Preferred Stock
|
Â
(5)
|
Â
(5)
|
Common Stock
|
1,064
|
$
(5)
|
I
|
See footnotes
(3)
(6)
|
Warrants to Purchase Series D-1 Convertible Preferred Stock
|
Â
(7)
|
Â
(8)
|
Common Stock
|
91,632
|
$
3.5
|
I
|
See footnotes
(3)
(6)
|
* |
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) |
33 1/3 % of the shares subject to the option shall vest on the first anniversary of the vesting start date of 7/26/08; 1/24th shall vest on each monthly anniversary thereafter. The options may be early exercised prior to vesting but any exercised and unvested shares are subject to a right of repurchase on behalf of the Issuer. |
(2) |
Series C Preferred Stock has no expiration date and is convertible at any time at the option of the holder and will automatically convert upon the closing of the Issuer's initial public offering, at a conversion ratio of one share of Common Stock for every two shares of Series C Preferred Stock, for no additional consideration. |
(3) |
By Foundation Medical Partners LP |
(4) |
Series D Preferred Stock has no expiration date and is convertible at any time at the option of the holder and will automatically convert upon the closing of the Issuer's initial public offering, at a conversion ratio of one share of Common Stock for every two shares of Series D Preferred Stock, for no additional consideration. |
(5) |
Mandatorily Convertible Preferred Stock has no expiration date and is convertible at any time at the option of the holder and will automatically convert upon the closing of the Issuer's initial public offering, at a conversion ratio of one share of Mandatorily Convertible Preferred Stock for every 66.88 shares of Common Stock, for no additional consideration. |
(6) |
The voting and disposition of the shares held by Foundation Medical Partners LP is determined by Andrew D. Firlik, Lee R. Wrubel and Harry T. Rein as the general partners of Foundation Medical Partners LP. Messrs. Firlik, Wrubel and Rein have shared voting and investment power over the shares held by Foundation Medical Partners LP. Messrs. Firlik, Wrubel and Rein disclaim beneficial ownership of these shares except to the extent of their pecuniary interest therein. |
(7) |
Warrants became exercisable on March 8, 2007. |
(8) |
Warrants to purchase Series D-1 Convertible Preferred will be automatically net exercised immediately prior to the closing of the Issuer's initial public offering. Series D-1 Preferred Stock has no expiration date and is convertible at any time at the option of the holder and will automatically convert upon the closing of the Issuer's initial public offering, at a conversion ratio of one share of Common Stock for every two shares of Series D-1 Preferred Stock, for no additional consideration. |