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