12/08/2021 | Press release | Distributed by Public on 12/08/2021 16:01
FORM 4
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549STATEMENT OF CHANGES IN 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. Title of Derivate Security | 2. Conversion or Exercise Price of Derivative Security | 3. Transaction Date (Month/Day/Year) | 3A. Deemed Execution Date, if any (Month/Day/Year) | 4. Transaction Code | 5. Number of Derivative Securities Acquired (A) or Disposed of (D) | 6. Date Exercisable and Expiration Date | 7. Title and Amount of Securities Underlying Derivative Security | 8. Price of Derivative Security | 9. Number of derivative Securities Beneficially Owned Following Reported Transaction(s) | 10. Ownership Form of Derivative Security: Direct (D) or Indirect (I) | 11. Nature of Indirect Beneficial Ownership |
Code | V | (A) | (D) | Date Exercisable | Expriation Date | Title | Amount or Number of Shares |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
Tangney Jeffrey DOXIMITY, INC. 500 THIRD STREET SAN FRANCISCO, CA94107 |
X | X | Chief Executive Officer | |
Tangney Schweikert Family Trust C/O DOXIMITY, INC. 500 THIRD STREET SAN FRANCISCO, CA94107 |
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X |
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Tangney Annuity Trust, LLC C/O DOXIMITY, INC. 500 THIRD STREET SAN FRANCISCO, CA94107 |
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X |
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/s/ Jennifer Chaloemtiarana, Attorney-in-Fact for Jeffrey Tangney | 2021-12-08 |
**Signature of Reporting Person | Date |
/s/ Jennifer Chaloemtiarana, Attorney-in-Fact for Tangney Schweikert Family Trust | 2021-12-08 |
**Signature of Reporting Person | Date |
/s/ Jennifer Chaloemtiarana, Attorney-in-Fact for Tangney Annuity Trust, LLC | 2021-12-08 |
**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) | Each share of Class B Common Stock, par value $0.001 per share (the "Class B Common Stock"), converted into one share of Class A Common Stock, par value $0.001 per share (the "Class A Common Stock"), at the option of the holder. |
(2) | These shares are owned directly by Jeffrey Tangney. |
(3) | These shares are owned directly by the Tangney Schweikert Family Trust, a ten percent owner of the Issuer, and indirectly by Mr. Tangney as trustee of such trust. Mr. Tangney is an officer, director and ten percent owner of the Issuer. |
(4) | Each share of Class B Common Stock is convertible into one share of Class A Common Stock at any time at the option of the holder. Each share of Class B Common Stock held by the Reporting Person will automatically convert into one share of Class A Common Stock, upon the following: (1) the sale or transfer of such share of Class B Common Stock, except for certain permitted transfers described in the Issuer's amended and restated certificate of incorporation; (2) the death or incapacity of the Reporting Person; and (3) on the final conversion date, defined as the earlier of (a) the tenth anniversary of the effectiveness of the registration statement in connection with the Issuer's initial public offering; or (b) the date specified by a vote of the holders of at least 66 2/3% of the outstanding shares of Class B Common Stock, voting as a single class. |
(5) | These shares are owned directly by Tangney Annuity Trust, LLC, a ten percent owner of the Issuer, and indirectly by Mr. Tangney as trustee of such trust. |