UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934, Section 17(a) of the Public Utility Holding Company Act of 1935 or Section 30(h) of the Investment Company Act of 1940 |
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | SEC 1473 (7-02) | ||
Persons who respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB control number. |
1. Title of Derivative Security (Instr. 4) |
2. Date Exercisable and Expiration Date (Month/Day/Year) |
3. Title and Amount of Securities Underlying Derivative Security (Instr. 4) |
4. Conversion or Exercise Price of Derivative Security | 5. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 5) |
6. Nature of Indirect Beneficial Ownership (Instr. 5) |
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Date Exercisable | Expiration Date | Title | Amount or Number of Shares | ||||
Stock Option (Right to Buy) | 11/28/2016 | 09/01/2024 | Common Stock, par value $0.01 per share | 1,167,960 | $ (2) (3) | I | By MEDX Ventures Group, LLC (1) |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
Gadot Harel C/O MICROBOT MEDICAL INC. 5 HAMADA STREET YOKNEAM, L3 20692 |
 X |  X |  Chairman and CEO |  |
/s/ Harel Gadot | 11/30/2016 | |
**Signature of Reporting Person | Date |
* | If the form is filed by more than one reporting person, see Instruction 5(b)(v). |
** | Intentional misstatements or omissions of facts constitute Federal Criminal Violations. See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). |
(1) | Mr. Gadot is the Chief Executive Officer, Company Group Chairman and majority equity owner of MEDX Venture Group and thus may be deemed to share voting and investment power over the shares beneficially owned by this entity. |
(2) | The exercise price of such options were to be determined pursuant to an independent valuation of the underlying shares on the date of grant, which valuation has not yet been obtained. The options were originally granted by Microbot Medical Ltd., a wholly-owned subsidiary of the Issuer ("Microbot"), to the Reporting Person in September 2014 and the underlying securities were the ordinary shares of Microbot. (Footnote continues in footnote (3)). |
(3) | On November 28, 2016, the Issuer assumed such options as part of its acquisition of Microbot. Upon the determination of the exercise price, the Reporting Person will amend this Form 3 accordingly. |