0001209191-11-057456.txt : 20111121
0001209191-11-057456.hdr.sgml : 20111121
20111121213626
ACCESSION NUMBER: 0001209191-11-057456
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: MAHAFFY PATRICK J
CENTRAL INDEX KEY: 0001266569
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-35347
FILM NUMBER: 111220282
MAIL ADDRESS:
STREET 1: C/O PHARMION CORP
STREET 2: 2525 28TH ST
CITY: BOULDER
STATE: CO
ZIP: 80301
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
c25049_4x0.xml
MAIN DOCUMENT DESCRIPTION
X0304
4
2011-11-21
0001466301
Clovis Oncology, Inc.
CLVS
0001266569
MAHAFFY PATRICK J
C/O CLOVIS ONCOLOGY, INC.
2525 28TH STREET, SUITE 100
BOULDER
CO
80301
1
1
0
0
President and CEO
Common Stock
2011-11-21
4
C
0
17835
A
828181
D
Common Stock
2011-11-21
4
C
0
17835
A
846016
D
Common Stock
2011-11-21
4
C
0
38605
A
884621
D
Common Stock
2011-11-21
4
C
0
16239
A
900860
D
Common Stock
2011-11-21
4
P
0
39927
13.00
A
940787
D
Series A-1 Convertible Preferred Stock
2011-11-21
4
C
0
51724
0
D
Common Stock
17835
0
D
Series A-2 Convertible Preferred Stock
2011-11-21
4
C
0
51724
0
D
Common Stock
17835
0
D
Series B Convertible Preferred Stock
2011-11-21
4
C
0
111957
0
D
Common Stock
38605
0
D
Convertible Promissory Notes
13.00
2011-11-21
4
C
0
206000
0
D
Common Stock
16239
0
D
The reported securities were convertible at any time, in whole or in part, at the option of the reporting person, had no expiration date, and automatically converted into shares of Common Stock on November 21, 2011, the closing of the Issuer's initial public offering, on a 2.9 for 1 basis.
The outstanding $206,000 principal amount of these 5% convertible promissory notes due May 25, 2012 and all accrued and unpaid interest thereon from and after May 25, 2011 automatically converted into shares of Common Stock on November 21, 2011, the closing of the Issuer's initial public offering, at a conversion price of $13.00, the per share price to the public of the Common Stock sold in the Issuer's initial public offering.
/s/ Patrick J. Mahaffy
2011-11-21