0000904454-11-000623.txt : 20111121 0000904454-11-000623.hdr.sgml : 20111121 20111121205439 ACCESSION NUMBER: 0000904454-11-000623 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20111121 FILED AS OF DATE: 20111121 DATE AS OF CHANGE: 20111121 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Halak Brian K CENTRAL INDEX KEY: 0001354718 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-35347 FILM NUMBER: 111220241 MAIL ADDRESS: STREET 1: C/O DOMAIN ASSOCIATES STREET 2: ONE PALMER SQUARE CITY: PRINCETON STATE: NJ ZIP: 08542 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: Clovis Oncology, Inc. CENTRAL INDEX KEY: 0001466301 STANDARD INDUSTRIAL CLASSIFICATION: PHARMACEUTICAL PREPARATIONS [2834] IRS NUMBER: 900475355 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 2525 28TH STREET STREET 2: SUITE 100 CITY: BOULDER STATE: CO ZIP: 80301 BUSINESS PHONE: (303) 625-5000 MAIL ADDRESS: STREET 1: 2525 28TH STREET STREET 2: SUITE 100 CITY: BOULDER STATE: CO ZIP: 80301 4 1 edgar.xml PRIMARY DOCUMENT X0304 4 2011-11-21 0001466301 Clovis Oncology, Inc. CLVS 0001354718 Halak Brian K C/O DOMAIN ASSOCIATES, LLC ONE PALMER SQUARE PRINCETON NJ 08542 0 0 1 0 Common Stock 2011-11-21 4 C 0 409192 A 409192 I By Domain Partners VII, L.P. Common Stock 2011-11-21 4 C 0 409192 A 818384 I By Domain Partners VII, L.P. Common Stock 2011-11-21 4 C 0 885696 A 1704080 I By Domain Partners VII, L.P. Common Stock 2011-11-21 4 C 0 370799 A 2074879 I By Domain Partners VII, L.P. Common Stock 2011-11-21 4 P 0 916058 13.00 A 2990937 I By Domain Partners VII, L.P. Common Stock 2011-11-21 4 C 0 6979 A 6979 I By DP VII Associates, L.P. Common Stock 2011-11-21 4 C 0 6979 A 13958 I By DP VII Associates, L.P. Common Stock 2011-11-21 4 C 0 15106 A 29064 I By DP VII Associates, L.P. Common Stock 2011-11-21 4 C 0 6324 A 35388 I By DP VII Associates, L.P. Common Stock 2011-11-21 4 P 0 15625 13.00 A 51013 I By DP VII Associates, L.P. Series A-1 Preferred Stock 2011-11-21 4 C 0 1186657 0 D Common Stock 409192 0 I By Domain Partners VII, L.P. Series A-2 Preferred Stock 2011-11-21 4 C 0 1186657 0 D Common Stock 409192 0 I By Domain Partners VII, L.P. Series B Preferred Stock 2011-11-21 4 C 0 2568521 0 D Common Stock 885696 0 I By Domain Partners VII, L.P. Convertible Promissory Note 2011-11-21 4 C 0 4703771.00 0 D Common Stock 370799 0 I By Domain Partners VII, L.P. Series A-1 Preferred Stock 2011-11-21 4 C 0 20240 0 D Common Stock 6979 0 I By DP VII Associates, L.P. Series A-2 Preferred Stock 2011-11-21 4 C 0 20240 0 D Common Stock 6979 0 I By DP VII Associates, L.P. Series B Preferred Stock 2011-11-21 4 C 0 43809 0 D Common Stock 15106 0 I By DP VII Associates, L.P. Convertible Promissory Note 2011-11-21 4 C 0 80229.00 0 D Common Stock 6324 0 I By DP VII Associates, L.P. All outstanding shares of the Issuer's preferred stock were automatically converted into Common Stock upon the closing of the Issuer's initial public offering (the "IPO"), for no additional consideration. The Convertible Promissory Note, plus interest accrued thereon through the closing of the IPO, automatically converted into Common Stock upon the closing of the IPO, based on the IPO price of $13.00 per share. The Reporting Person also indirectly beneficially owns 32,758 shares of Common Stock held by Domain Associates, LLC. The Reporting Person is a Managing Member of One Palmer Square Associates VII, LLC, which is the sole general partner of Domain Partners VII, L.P. and DP VII Associates, L.P. and Domain Associates, LLC. Pursuant to Instruction (4)(b)(iv) of Form 4, the Reporting Person has elected to report as indirectly beneficially owned the entire number of securities beneficially owned by each such entity. The Reporting Person disclaims beneficial ownership of any securities, and any proceeds thereof, that exceed his or her pecuniary interest therein and/or that are not actually distributed to him or her. /s/Kathleen K. Schoemaker, Attorney-in-Fact 2011-11-21