FORM 3 |
UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934 or Section 30(h) of the Investment Company Act of 1940 |
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1. Name and Address of Reporting Person*
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year) 11/13/2018 |
3. Issuer Name and Ticker or Trading Symbol
VAPOTHERM INC [ VAPO ] |
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
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5. If Amendment, Date of Original Filed
(Month/Day/Year) |
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6. Individual or Joint/Group Filing (Check Applicable Line)
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Table I - Non-Derivative Securities Beneficially Owned | |||
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1. Title of Security (Instr. 4) | 2. Amount of Securities Beneficially Owned (Instr. 4) | 3. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) | 4. Nature of Indirect Beneficial Ownership (Instr. 5) |
Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) | |||||||
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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: 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 A Convertible Preferred Stock | (1) | (1) | Common Stock | 372,206 | (1) | D | |
Series B Convertible Preferred Stock | (2) | (2) | Common Stock | 145,252 | (2) | D | |
Series C Convertible Preferred Stock | (3) | (3) | Common Stock | 430,937 | (3) | D | |
Series D Convertible Preferred Stock | (4) | (4) | Common Stock | 345,519 | (4) | D | |
Warrant to purchase Series A Convertible Preferred Stock | (5) | (5) | Series A Convertible Preferred Stock | 20,888 | (5) | D |
1. Name and Address of Reporting Person*
(Street)
Relationship of Reporting Person(s) to Issuer
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1. Name and Address of Reporting Person*
(Street)
Relationship of Reporting Person(s) to Issuer
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1. Name and Address of Reporting Person*
(Street)
Relationship of Reporting Person(s) to Issuer
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1. Name and Address of Reporting Person*
(Street)
Relationship of Reporting Person(s) to Issuer
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1. Name and Address of Reporting Person*
(Street)
Relationship of Reporting Person(s) to Issuer
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Explanation of Responses: |
1. Series A Convertible Preferred Stock is convertible into shares of common stock at any time at the holder's election and automatically upon the consummation of a qualified public offering of the registrant. There is no expiration date for the Series A Convertible Preferred Stock. Consists of (i) 163,365 shares held by SightLine Healthcare Opportunity Fund II, (ii) 56,994 shares held by SightLine Healthcare Opportunity Fund II-A and (iii) 151,847 shares held by SightLine Healthcare Opportunity Fund II-B. |
2. Series B Convertible Preferred Stock is convertible into shares of common stock at any time at the holder's election and automatically upon the consummation of a qualified public offering of the registrant. There is no expiration date for the Series B Convertible Preferred Stock. Consists of (i) 63,753 shares held by SightLine Healthcare Opportunity Fund II, (ii) 22,241 shares held by SightLine Healthcare Opportunity Fund II-A and (iii) 59,258 shares held by SightLine Healthcare Opportunity Fund II-B. |
3. Series C Convertible Preferred Stock is convertible into shares of common stock at any time at the holder's election and automatically upon the consummation of a qualified public offering of the registrant. There is no expiration date for the Series C Convertible Preferred Stock. Consists of (i) 189,144 shares held by SightLine Healthcare Opportunity Fund II, (ii) 65,986 shares held by SightLine Healthcare Opportunity Fund II-A and (iii) 175,807 shares held by SightLine Healthcare Opportunity Fund II-B. |
4. Series D Convertible Preferred Stock is convertible into shares of common stock at any time at the holder's election and automatically upon the consummation of a qualified public offering of the registrant. There is no expiration date for the Series D Convertible Preferred Stock. Consists of (i) 137,866 shares held by SightLine Healthcare Opportunity Fund II, (ii) 48,098 shares held by SightLine Healthcare Opportunity Fund II-A, (iii) 128,145 shares held by SightLine Healthcare Opportunity Fund II-B and (iv) 31,410 shares held by SightLine Investors, LLC. |
5. The warrants to purchase Series A Convertible Preferred Stock are exercisable at any time at the holder's election, and have an expiration date of March 14, 2022. Consists of (i) warrants to purchase 9,168 shares held by SightLine Healthcare Opportunity Fund II, (ii) warrants to purchase 3,198 shares held by SightLine Healthcare Opportunity Fund II-A and (iii) warrants to purchase 8,522 shares held by SightLine Healthcare Opportunity Fund II-B. |
Remarks: |
Exhibit List Exhibit 24 - Power of Attorney |
/s/ John Landry, as Attorney-In-Fact for SightLine Partners LLC | 11/13/2018 | |
/s/ John Landry, as Attorney-In-Fact for SightLine Healthcare Opportunity Fund II, L.P. | 11/13/2018 | |
/s/ John Landry, as Attorney-In-Fact for SightLine Healthcare Opportunity Fund II-A, L.P. | 11/13/2018 | |
/s/ John Landry, as Attorney-In-Fact for SightLine Healthcare Opportunity Fund II-B, L.P. | 11/13/2018 | |
/s/ John Landry, as Attorney-In-Fact for SightLine Investors, LLC | 11/13/2018 | |
** Signature of Reporting Person | Date | |
Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | ||
* 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). | ||
Note: File three copies of this Form, one of which must be manually signed. If space is insufficient, see Instruction 6 for procedure. | ||
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 Number. |