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 B Convertible Preferred Stock
|
Â
(1)
|
Â
(1)
|
Common Stock
|
113,586
|
$
(1)
|
D
|
Â
|
Series D Convertible Preferred Stock
|
Â
(2)
|
Â
(2)
|
Common Stock
|
142,857
|
$
(2)
|
D
|
Â
|
Series B Convertible Preferred Stock
|
Â
(1)
|
Â
(1)
|
Common Stock
|
113,586
|
$
(1)
|
I
|
See footnote
(3)
|
Series D Convertible Preferred Stock
|
Â
(2)
|
Â
(2)
|
Common Stock
|
142,857
|
$
(2)
|
I
|
See footnote
(3)
|
Stock Option (right to buy)
|
Â
(4)
|
10/22/2017 |
Common Stock
|
60,000
|
$
2.59
|
D
|
Â
|
Stock Option (right to buy)
|
Â
(4)
|
09/21/2018 |
Common Stock
|
20,000
|
$
1.81
|
D
|
Â
|
Stock Option (right to buy)
|
Â
(4)
|
11/04/2019 |
Common Stock
|
20,000
|
$
2.12
|
D
|
Â
|
Stock Option (right to buy)
|
Â
(4)
|
05/02/2021 |
Common Stock
|
53,000
|
$
5.54
|
D
|
Â
|
Common Stock Warrant (right to buy)
|
Â
(4)
|
12/17/2015 |
Common Stock
|
8,766
|
$
3
|
D
|
Â
|
Common Stock Warrant (right to buy)
|
Â
(4)
|
12/17/2015 |
Common Stock
|
8,766
|
$
3
|
I
|
See footnote
(5)
|
* |
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) |
Each share of Series B Convertible Preferred Stock will automatically convert into approximately 1.5435 shares of Common Stock upon the closing of the issuer's initial public offering. The shares have no expiration date. |
(2) |
Each share of Series D Convertible Preferred Stock will automatically convert into one share of Common Stock upon the closing of the issuer's initial public offering. The shares have no expiration date. |
(3) |
These shares are held by the Robert C. Gay 1998 Family Trust, of which Dr. Gay is the grantor. Dr. Gay disclaims beneficial ownership of these shares, except to the extent of his pecuniary interest therein, and the inclusion of these shares in this report shall not be deemed an admission of beneficial ownership of any such shares for purposes of Section 16 of the Securities Exchange Act of 1934, as amended, or for any other purpose. |
(4) |
This security is fully vested. |
(5) |
This warrant is held by the Robert C. Gay 1998 Family Trust, of which Dr. Gay is the grantor. Dr. Gay disclaims beneficial ownership of this warrant and the shares underlying this warrant, except to the extent of his pecuniary interest therein, and the inclusion of this warrant in this report shall not be deemed an admission of beneficial ownership of this warrant or any shares underlying this warrant for purposes of Section 16 of the Securities Exchange Act of 1934, as amended, or for any other purpose. |