0000899243-17-019055.txt : 20170726 0000899243-17-019055.hdr.sgml : 20170726 20170726170025 ACCESSION NUMBER: 0000899243-17-019055 CONFORMED SUBMISSION TYPE: 3 PUBLIC DOCUMENT COUNT: 2 CONFORMED PERIOD OF REPORT: 20170724 FILED AS OF DATE: 20170726 DATE AS OF CHANGE: 20170726 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Venkatesan Jay CENTRAL INDEX KEY: 0001413350 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-37449 FILM NUMBER: 17983559 MAIL ADDRESS: STREET 1: C/O AYER CAPITAL MANAGEMENT, LP STREET 2: 230 CALIFORNIA ST, SUITE 600 CITY: SAN FRANCISCO STATE: CA ZIP: 94111 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: ALPINE IMMUNE SCIENCES, INC. CENTRAL INDEX KEY: 0001626199 STANDARD INDUSTRIAL CLASSIFICATION: PHARMACEUTICAL PREPARATIONS [2834] IRS NUMBER: 208969493 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 201 ELLIOTT AVE. WEST, SUITE 230 CITY: SEATTLE STATE: WA ZIP: 98119 BUSINESS PHONE: 206-788-4545 MAIL ADDRESS: STREET 1: 201 ELLIOTT AVE. WEST, SUITE 230 CITY: SEATTLE STATE: WA ZIP: 98119 FORMER COMPANY: FORMER CONFORMED NAME: Nivalis Therapeutics, Inc. DATE OF NAME CHANGE: 20150211 FORMER COMPANY: FORMER CONFORMED NAME: N30 Pharmaceuticals, Inc. DATE OF NAME CHANGE: 20141121 3 1 doc3.xml FORM 3 SUBMISSION X0206 3 2017-07-24 1 0001626199 ALPINE IMMUNE SCIENCES, INC. ALPN 0001413350 Venkatesan Jay C/O ALPINE IMMUNE SCIENCES, INC. 201 ELLIOTT AVENUE WEST, SUITE 230 SEATTLE WA 98119 1 1 0 0 President Exhibit 24.1 - Power of Attorney /s/ James Paul Rickey, attorney-in-fact 2017-07-26 EX-24.1 2 attachment1.htm EX-24.1 DOCUMENT
                                  POWER OF ATTORNEY

        Know all by these presents, that the undersigned hereby makes,
constitutes and appoints each of David Miller and James Paul Rickey, or either
of them acting individually, and with full power of substitution, the
undersigned's true and lawful attorney-in-fact to:

      (1)   prepare, execute in the undersigned's name and on the undersigned's
            behalf, and submit to the U.S. Securities and Exchange Commission
            (the "SEC") a Form ID, including amendments thereto, and any other
            documents necessary or appropriate to obtain codes and passwords
            enabling the undersigned to make electronic filings with the SEC of
            reports required by Section 16(a) of the Securities Exchange Act of
            1934 or any rule or regulation of the SEC;

      (2)   execute for and on behalf of the undersigned, in the undersigned's
            capacity as an officer and/or director of Alpine Immune Sciences,
            Inc. (the "Company"), Forms 3, 4, and 5 in accordance with Section
            16(a) of the Securities Exchange Act of 1934 and the rules
            thereunder;

      (3)   do and perform any and all acts for and on behalf of the undersigned
            which may be necessary or desirable to complete and execute any such
            Form 3, 4, or 5, complete and execute any amendment or amendments
            thereto, and timely file such form with the SEC and any stock
            exchange or similar authority; and

      (4)   take any other action of any type whatsoever in connection with the
            foregoing which, in the opinion of such attorney-in-fact, may be of
            benefit to, in the best interest of, or legally required by, the
            undersigned, it being understood that the documents executed by such
            attorney-in-fact on behalf of the undersigned pursuant to this Power
            of Attorney shall be in such form and shall contain such terms and
            conditions as such attorney-in-fact may approve in such attorney-in-
            fact's discretion.

        The undersigned hereby grants to each such attorney-in-fact full power
and authority to do and perform any and every act and thing whatsoever
requisite, necessary, or proper to be done in the exercise of any of the rights
and powers herein granted, as fully to all intents and purposes as the
undersigned might or could do if personally present, with full power of
substitution or revocation, hereby ratifying and confirming all that such
attorney-in-fact, or such attorney-in-fact's substitute or substitutes, shall
lawfully do or cause to be done by virtue of this power of attorney and the
rights and powers herein granted. The undersigned acknowledges that the
foregoing attorneys-in-fact, in serving in such capacity at the request of the
undersigned, are not assuming, nor is the Company assuming, any of the
undersigned's responsibilities to comply with Section 16 of the Securities
Exchange Act of 1934.

        This Power of Attorney shall remain in full force and effect until the
undersigned is no longer required to file Forms 3, 4, and 5 with respect to the
undersigned's holdings of and transactions in securities issued by the Company,
unless earlier revoked by the undersigned in a signed writing delivered to the
foregoing attorneys-in-fact.

        IN WITNESS WHEREOF, the undersigned has caused this Power of Attorney to
be executed as of this 15th day of July, 2017.


                                                /s/ Jay Venkatesan
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                                                       Signature

                                                Jay Venkatesan
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                                                       Print Name