SEC Form 4
| FORM 4 | UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP 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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| Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b). | ||||||||||||||||
1. Name and Address of Reporting Person*
(Street)
| 2. Issuer Name and Ticker or Trading Symbol Doximity, Inc. [ DOCS ] | 5. Relationship of Reporting Person(s) to Issuer (Check all applicable)
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| 3. Date of Earliest Transaction (Month/Day/Year) 12/02/2021 | ||||||||||||||||||||||||||
| 4. If Amendment, Date of Original Filed (Month/Day/Year) | 6. Individual or Joint/Group Filing (Check Applicable Line)
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| Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned | ||||||||||
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| 1. Title of Security (Instr. 3) | 2. Transaction Date (Month/Day/Year) | 2A. Deemed Execution Date, if any (Month/Day/Year) | 3. Transaction Code (Instr. 8) | 4. Securities Acquired (A) or Disposed Of (D) (Instr. 3, 4 and 5) | 5. Amount of Securities Beneficially Owned Following Reported Transaction(s) (Instr. 3 and 4) | 6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) | 7. Nature of Indirect Beneficial Ownership (Instr. 4) | |||
| Code | V | Amount | (A) or (D) | Price | ||||||
| Class A Common Stock | 12/02/2021 | C(1) | 4,300,000 | A | (1) | 4,300,000 | D(4) | |||
| Class A Common Stock | 12/02/2021 | J(2) | 4,300,000 | D | $0.00 | 0 | D | |||
| Class A Common Stock | 12/02/2021 | J(2) | 1,101,094 | A | $0.00 | 1,101,094 | I | By: InterWest Management Partners X, LLC(4) | ||
| Class A Common Stock | 12/02/2021 | J(3) | 1,101,094 | D | $0.00 | 0 | I | By: InterWest Management Partners X, LLC(4) | ||
| Class A Common Stock | 12/02/2021 | J(3) | 41,070 | A | $0.00 | 81,696 | I | By: Khaled A. Nasr(4) | ||
| Class A Common Stock | 12/02/2021 | J(3) | 27,527 | A | $0.00 | 54,756 | I | By: Keval Desai(4) | ||
| Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) | |||||||||||||||
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| 1. Title of Derivative Security (Instr. 3) | 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 (Instr. 8) | 5. Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr. 3, 4 and 5) | 6. Date Exercisable and Expiration Date (Month/Day/Year) | 7. Title and Amount of Securities Underlying Derivative Security (Instr. 3 and 4) | 8. Price of Derivative Security (Instr. 5) | 9. Number of derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4) | 10. Ownership Form: Direct (D) or Indirect (I) (Instr. 4) | 11. Nature of Indirect Beneficial Ownership (Instr. 4) | ||||
| Code | V | (A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares | ||||||||
| Class B Common Stock | (5) | 12/02/2021 | C(1) | 4,300,000 | (5) | (5) | Class A Common Stock | 4,300,000 | $0.00 | 8,556,998 | D(4) | ||||
1. Name and Address of Reporting Person*
(Street)
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1. Name and Address of Reporting Person*
(Street)
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1. Name and Address of Reporting Person*
(Street)
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1. Name and Address of Reporting Person*
(Street)
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| Explanation of Responses: |
| 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. Represents pro rata in-kind distribution by InterWest Partners X, LP ("IW10") without consideration to its limited and general partners in accordance with the terms of the InterWest Partners X, LP Limited Partnership Agreement. Includes 1,101,094 shares distributed to InterWest Management Partners X, LLC ("IMP10") its general partner. |
| 3. Represents pro rata in-kind distribution by IMP10 without consideration to its members in accordance with the terms of the InterWest Management Partners X, LLC Operating Agreement. Includes 41,070 shares distributed to Khaled A. Nasr ("Nasr"), 27,527 shares distributed to Keval Desai ("Desai") and 249,778 shares distributed to Gilbert H. Kliman ("Kliman"), as reported on Kliman's separate Form 4 in his own name. |
| 4. These shares are directly held by IW10. IMP10 is the general partner of IW10. Gilbert H. Kliman is the Managing Director of IMP10. Keval Desai and Khaled Nasr are Venture Members of IMP10. Each of IMP10, Gilbert H. Kliman, Keval Desai and Khaled Nasr may be deemed to beneficially own the shares held by IW10, and each of IMP10, Gilbert H. Kliman, Keval Desai and Khaled Nasr disclaims beneficial ownership of only the shares held by IW10, except to the extent of its or his pecuniary interest therein. |
| 5. 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 IPO; 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. |
| Remarks: |
| Gilbert H. Kliman, a Managing Director of IMP10, is also a Director of the Issuer and has filed a separate Form 4 in his own name. |
| /s/ Karen A. Wilson, Attorney-in Fact for InterWest Partners X, LP | 12/06/2021 | |
| /s/ Karen A. Wilson, Attorney-in Fact for InterWest Management Partners X, LLC | 12/06/2021 | |
| /s/ Karen A. Wilson, Attorney-in Fact for Khlaed A. Nasr | 12/06/2021 | |
| /s/ Karen A. Wilson, Attorney-in Fact for Keval Desai | 12/06/2021 | |
| ** 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 4 (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. | ||