0001209191-21-028401.txt : 20210426
0001209191-21-028401.hdr.sgml : 20210426
20210426190206
ACCESSION NUMBER: 0001209191-21-028401
CONFORMED SUBMISSION TYPE: 4
PUBLIC DOCUMENT COUNT: 1
CONFORMED PERIOD OF REPORT: 20210422
FILED AS OF DATE: 20210426
DATE AS OF CHANGE: 20210426
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: HAQUE PROMOD
CENTRAL INDEX KEY: 0001089744
STATE OF INCORPORATION: CA
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-40353
FILM NUMBER: 21855445
MAIL ADDRESS:
STREET 1: C/O NORWEST VENTURE PARTNERS
STREET 2: 525 UNIVERSITY AVENUE, SUITE 800
CITY: PALO ALTO
STATE: CA
ZIP: 94301
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: Crowe Jeffrey
CENTRAL INDEX KEY: 0001535261
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-40353
FILM NUMBER: 21855446
MAIL ADDRESS:
STREET 1: 525 UNIVERSITY AVENUE
STREET 2: SUITE 800
CITY: PALO ALTO
STATE: CA
ZIP: 94301
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: Norwest Venture Partners XIV, LP
CENTRAL INDEX KEY: 0001842721
STATE OF INCORPORATION: DE
FISCAL YEAR END: 1231
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-40353
FILM NUMBER: 21855447
BUSINESS ADDRESS:
STREET 1: 525 UNIVERSITY AVENUE
STREET 2: SUITE 800
CITY: PALO ALTO
STATE: CA
ZIP: 94301
BUSINESS PHONE: 650-321-8000
MAIL ADDRESS:
STREET 1: 525 UNIVERSITY AVENUE
STREET 2: SUITE 800
CITY: PALO ALTO
STATE: CA
ZIP: 94301
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: Kossow Jon Erik
CENTRAL INDEX KEY: 0001726084
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-40353
FILM NUMBER: 21855444
MAIL ADDRESS:
STREET 1: 525 UNIVERSITY AVENUE, SUITE 800
CITY: PALO ALTO
STATE: CA
ZIP: 94025
ISSUER:
COMPANY DATA:
COMPANY CONFORMED NAME: IMPEL NEUROPHARMA INC
CENTRAL INDEX KEY: 0001445499
STANDARD INDUSTRIAL CLASSIFICATION: PHARMACEUTICAL PREPARATIONS [2834]
IRS NUMBER: 263058238
STATE OF INCORPORATION: DE
FISCAL YEAR END: 1231
BUSINESS ADDRESS:
STREET 1: 201 ELLIOTT AVE. W
STREET 2: SUITE 260
CITY: SEATTLE
STATE: WA
ZIP: 98119
BUSINESS PHONE: 206-568-1466
MAIL ADDRESS:
STREET 1: 201 ELLIOTT AVE. W
STREET 2: SUITE 260
CITY: SEATTLE
STATE: WA
ZIP: 98119
4
1
doc4.xml
FORM 4 SUBMISSION
X0306
4
2021-04-22
0
0001445499
IMPEL NEUROPHARMA INC
IMPL
0001842721
Norwest Venture Partners XIV, LP
525 UNIVERSITY AVENUE
SUITE 800
PALO ALTO
CA
94301
0
0
1
0
0001535261
Crowe Jeffrey
525 UNIVERSITY AVENUE
SUITE 800
PALO ALTO
CA
94301
0
0
1
0
0001089744
HAQUE PROMOD
525 UNIVERSITY AVENUE
SUITE 800
PALO ALTO
CA
94301
0
0
1
0
0001726084
Kossow Jon Erik
525 UNIVERSITY AVENUE
SUITE 800
PALO ALTO
CA
94301
0
0
1
0
5% Convertible Note due 2021
2021-04-22
4
J
0
1325893.04
0.00
A
2021-12-31
Common Stock
98927
1325893.04
D
The convertible promissory note was issued by the issuer in March 2021 and the outstanding principal and accrued interest will automatically convert into the number of shares of the issuer's Common Stock set forth above upon the closing of the issuer's initial public offering (the "IPO") at $13.50 per share (90% of the IPO price). The conversion price became fixed upon pricing of the issuer's IPO on April 22, 2021.
/s/ Matthew De Dominicis, Chief Financial Officer
2021-04-26
/s/ Matthew De Dominicis, Attorney-in-Fact for Jeffrey Crowe
2021-04-26
/s/ Matthew De Dominicis, Attorney-in-Fact for Promod Haque
2021-04-26
/s/ Matthew De Dominicis, Attorney-in-Fact for Jon Erik Kossow
2021-04-26