SEC Form 4 · accession 0001415889-15-003934
Medovex Corp. · MDVX
Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗
Reporting owner
Steve Gorlin
Director
Period of report
Nov 9, 2015
Accepted (ET)
Nov 30, 2015 · 4:40 pm EST
Rule 10b5-1 plan
unknown — predates the checkbox
Issuer CIK
0001591165
Table I — non-derivative securities
| Security | Date | Code | Shares | Price | A/D | Owned after | D/I | Nature of ownership |
|---|---|---|---|---|---|---|---|---|
| Common StockF1 | Nov 24, 2015 | P | 40,000 | $1.449 | A | 369,462 | D |
Table II — derivative securities
| Security | Conv. / exercise price | Date | Code | Shares | A/D | Exercisable | Expires | Underlying | Underlying shares | Owned after | D/I |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Convertible NoteF2,F3 | — | Nov 9, 2015 | P | 1 | A | Nov 9, 2015 | Nov 9, 2015 | Common Stock | — | 1 | D |
| WarrantsF3 | $2.20 | Nov 9, 2015 | P | 500,000 | A | Nov 9, 2015 | Nov 9, 2018 | Common Stock | 500,000 | 0 | D |
Explanation of responses
- F1Includes 125,000 shares held by Mr. Gorlin's spouse, Deborah Gorlin. Mr. Gorlin disclaims beneficial ownership of Deborah Gorlin's shares.
- F2On November 9, 2015, the Company issued a convertible promissory note (the "Note") to Steve Gorlin. The Note's principal amount is $2,000,000 and bears interest at a rate of 5.5% annually and will mature two years from the issuance date. The Note is convertible such number of shares of common stock equal to the quotient of (a) the outstanding principal amount and accrued interest of the Note as of date of conversion, divided by (b) $2.00, subject to adjustment.
- F3In addition to the Note, the Reporting Person received a warrant to purchase 500,000 shares of common stock, exercisable at $2.20 per share for three years.