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) 11/14/2007 |
3. Issuer Name and Ticker or Trading Symbol
EnteroMedics Inc [ ETRM ] |
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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) |
Common Stock | 99,944 | I | Revocable Trust |
Common Stock | 19,286 | I | Family Limited Partnership |
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 | ||||
Stock Option (right to buy) | 08/16/2004(1) | 08/16/2014 | Common Stock | 69,451 | 0.46 | D | |
Stock Option (right to buy) | (2) | 04/27/2015 | Common Stock | 47,495 | 0.46 | D | |
Stock Option (right to buy) | 04/20/2007(3) | 04/20/2016 | Common Stock | 40,660 | 0.46 | D | |
Stock Option (right to buy) | 02/06/2008(3) | 02/06/2017 | Common Stock | 252,748 | 5.19 | D | |
Series A Convertible Preferred Stock | (4) | (4) | Common Stock | 7,623 | (4) | I | Revocable Trust |
Series B Convertible Preferred Stock | (5) | (5) | Common Stock | 10,368 | (5) | I | Revocable Trust |
Series C Convertible Preferred Stock | (5) | (5) | Common Stock | 6,332 | (5) | I | Revocable Trust |
Series B Convertible Preferred Stock | (5) | (5) | Common Stock | 5,126 | (5) | I | Spouse Revocable Trust |
Series C Convertible Preferred Stock | (5) | (5) | Common Stock | 3,166 | (5) | I | Spouse Revocable Trust |
Warrants (right to buy) | (6) | 11/13/2010 | Common Stock | 2,029 | 0.4333 | I | Revocable Trust |
Warrants (right to buy) | (6) | 11/13/2010 | Common Stock | 1,015 | 0.4333 | I | Spouse Revocable Trust |
Explanation of Responses: |
1. Vests 50% immediately, 25% on the first anniversary of the date of grant and 1/36th per month for 36 months thereafter, beginning the date shown. |
2. Currently 100% vested in accordance with achievement of milestone vesting terms. |
3. Vests 25% on the first anniversary of the date of grant and 1/36th per month for 36 months thereafter, beginning the date shown. |
4. The convertible preferred stock will automatically convert into 11,798 shares of common stock upon completion of the initial public offering. |
5. The convertible preferred stock will automatically convert one-to-one into common stock upon completion of the initial public offering. |
6. Immediately exercisable. |
/s/ Mark B. Knudson | 11/13/2007 | |
** 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. |