Establishment Labs (ESTA) Form 3 ESTABLISHMENT LABS / Quiros Juan Jose Chacon ownership change

SEC Form 3

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^*

Chacon Quiros Juan Jose

(Last) (First) (Middle)

C/O MOTIVA USA LLC

16192 COASTAL HIGHWAY

(Street)

LEWES DE 19958

(City) (State) (Zip)

2. Date of Event Requiring Statement (Month/Day/Year)
07/18/2018

3. Issuer Name and Ticker or Trading Symbol
ESTABLISHMENT LABS HOLDINGS INC. [ ESTA ]

4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)

X	Director	10% Owner
X	Officer (give title below)	Other (specify below)
Chief Executive Officer

5. If Amendment, Date of Original Filed (Month/Day/Year)

6. Individual or Joint/Group Filing (Check Applicable Line)

X	Form filed by One Reporting Person
	Form filed by More than One Reporting Person

Table I - Non-Derivative Securities Beneficially Owned
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)
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
Class A Ordinary Shares	(1)	(1)	Common Shares	237,026	(1)	D
Class A Ordinary Shares	(1)	(1)	Common Shares	1,128,264	(1)	I	See Footnote(2)
Restricted Stock Award	(3)	09/09/2019	Class A Ordinary Shares	57,214	0.0	D

Explanation of Responses:

1. Each Class A Ordinary Share shall automatically convert into Common Shares on a one-for-one basis upon the closing of the Issuer's initial public offering of Common Shares and has no expiration date.

2. The shares are held by Sariel LLC. The Reporting Person is a shareholder of Sariel LLC and has voting and dispositive power over the shares owned by Sariel LLC. The Reporting Person disclaims beneficial ownership of the shares held by Sariel LLC, except to the extent of his pecuniary interest therein.

3. The award, originally granted for 294,240 shares, of which 237,026 shares have been released, vested as to one half of the shares on September 9, 2016 and as to 1/72nd of the shares each month thereafter, subject to the Reporting Person continuing as a service provider through each such date.

Remarks:

Exhibit 24 - Power of Attorney

	/s/ Renee Gaeta, by power of attorney	07/18/2018
	** 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).
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