Regulatory Filings • Mar 26, 2018
Regulatory Filings
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OMB Number: 3235-0076
| Notice of Exempt Offering of Securities | Estimated average burden hours per response |
4.00 | ||||
|---|---|---|---|---|---|---|
| 1. Issuer's Identity | ||||||
| CIK (Filer ID Number) | Previous Names | None | Entity Type | |||
| 0001614744 | ||||||
| Kitov | Corporation | |||||
| Pharmaceuticals Holdings Ltd. |
Limited Partnership | |||||
| Name of Issuer | Limited Liability Company | |||||
| Kitov Pharma Ltd. | Mainrom Line Logistics Ltd. |
General Partnership | ||||
| Business Trust | ||||||
| Jurisdiction of Incorporation/Organization | X Other (Specify) Limited company |
|||||
| ISRAEL Year of Incorporation/Organization |
||||||
| X Over Five Years Ago | ||||||
| Within Last Five Years (Specify Year) | ||||||
| Yet to Be Formed | ||||||
| 2. Principal Place of Business and Contact Information | ||||||
| Name of Issuer | ||||||
| Kitov Pharma Ltd. | ||||||
| Street Address 1 | Street Address 2 | |||||
| ONE AZRIELI CENTER | ROUND BUILDING, 19TH FLOOR | |||||
| City | State/Province/Country | ZIP/PostalCode | Phone Number of Issuer | |||
| TEL AVIV | ISRAEL | 6701101 | 972-3-9333121 | |||
| 3. Related Persons | ||||||
| Last Name | First Name | Middle Name | ||||
| Israel | Isaac | |||||
| Street Address 1 | Street Address 2 | |||||
| One Azrieli Center City |
Round Building, 19th Floor State/Province/Country |
ZIP/PostalCode | ||||
| Tel Aviv | ISRAEL | 6701101 | ||||
| Relationship: | X Executive Officer |
X Director |
Promoter | |||
| Clarification of Response (if Necessary): | ||||||
| Chief Executive Officer and Director of the Issuer | ||||||
| Last Name | First Name | Middle Name | ||||
| Waymack Street Address 1 |
John Paul | Street Address 2 | ||||
| One Azrieli Center | Round Building, 19th Floor | |||||
| City | State/Province/Country | ZIP/PostalCode | ||||
| Tel Aviv | ISRAEL | 6701101 | ||||
| Relationship: | X Executive Officer |
X Director |
Promoter | |||
| Clarification of Response (if Necessary): | ||||||
| Chief Medical Officer and Chairman of the Board of Directors | ||||||
| Last Name | First Name | Middle Name | ||||
| Rock | Simcha | |||||
| Street Address 1 | Street Address 2 | |||||
| One Azrieli Center City |
Round Building, 19th Floor State/Province/Country |
ZIP/PostalCode | ||||
| Tel Aviv | ISRAEL | 6701101 | ||||
| Relationship: | X Executive Officer |
X Director |
Promoter |
Clarification of Response (if Necessary):
| Last Name Steinberg |
First Name Steven |
Middle Name |
|---|---|---|
| Street Address 1 | Street Address 2 | |
| One Azrieli Center | Round Building, 19th Floor | |
| City | State/Province/Country | ZIP/PostalCode |
| Tel Aviv | ISRAEL | 6701101 |
| Relationship: Executive Officer |
X Director Promoter |
|
| Clarification of Response (if Necessary): | ||
| Director | ||
| Last Name Agmon |
First Name Ido |
Middle Name |
| Street Address 1 | Street Address 2 | |
| One Azrieli Center | Round Building, 19th Floor | |
| City | State/Province/Country | ZIP/PostalCode |
| Tel Aviv | ISRAEL | 6701101 |
| Relationship: Executive Officer |
X Director Promoter |
|
| Clarification of Response (if Necessary): | ||
| Director | ||
| Last Name | First Name | Middle Name |
| Weber | Arye | |
| Street Address 1 | Street Address 2 | |
| One Azrieli Center | Round Building, 19th Floor | |
| City | State/Province/Country | ZIP/PostalCode |
| Tel Aviv | ISRAEL | 6701101 |
| Relationship: Executive Officer |
X Director Promoter |
|
| Clarification of Response (if Necessary): | ||
| Director | ||
| Last Name Tzror |
First Name Ran |
Middle Name |
| Street Address 1 | Street Address 2 | |
| One Azrieli Center | Round Building, 19th Floor | |
| City | State/Province/Country | ZIP/PostalCode |
| Tel Aviv | ISRAEL | 6701101 |
| Relationship: Executive Officer |
X Director Promoter |
|
| Clarification of Response (if Necessary): | ||
| Director | ||
| Last Name | First Name | Middle Name |
| Stern-Raff | Revital | |
| Street Address 1 | Street Address 2 | |
| One Azrieli Center | Round Building, 19th Floor | |
| City | State/Province/Country | ZIP/PostalCode |
| Tel Aviv | ISRAEL | 6701101 |
| Relationship: Executive Officer |
X Director Promoter |
|
| Clarification of Response (if Necessary): | ||
| Director | ||
| Last Name | First Name | Middle Name |
| Ben-Menachem | Gil | |
| Street Address 1 | Street Address 2 | |
| One Azrieli Center | Round Building, 19th Floor | |
| City | State/Province/Country | ZIP/PostalCode |
| Tel Aviv | ISRAEL | 6701101 |
| Relationship: X Executive Officer |
X Director Promoter |
|
| Clarification of Response (if Necessary): | ||
| Vice President of Business Development and Director | ||
| Last Name | First Name | Middle Name |
| Reuveni | Hadas |
| Street Address 1 One Azrieli Center City Tel Aviv |
Street Address 2 Round Building, 19th Floor State/Province/Country ZIP/PostalCode ISRAEL 6701101 |
|---|---|
| Relationship: X Executive Officer |
Director Promoter |
| Clarification of Response (if Necessary): | |
| Founder and Chief Technology Officer of TyrNovo Ltd., a subsidiary of the Filer | |
| 4. Industry Group | |
| Agriculture Banking & Financial Services Commercial Banking |
Health Care Retailing Restaurants Biotechnology Technology Health Insurance |
| Insurance Investing Investment Banking |
Computers Hospitals & Physicians Telecommunications X Pharmaceuticals Other Technology Other Health Care |
| Pooled Investment Fund Is the issuer registered as an investment company under the Investment Company Act of 1940? Yes No Other Banking & Financial Services |
Travel Manufacturing Airlines & Airports Real Estate Lodging & Conventions Commercial Tourism & Travel Construction Services REITS & Finance Other Travel Residential |
| Business Services Energy Coal Mining Electric Utilities Energy Conservation Environmental Services Oil & Gas Other Energy |
Other Other Real Estate |
| 5. Issuer Size | |
| Revenue Range No Revenues \$1 - \$1,000,000 \$1,000,001 - \$5,000,000 \$5,000,001 - \$25,000,000 \$25,000,001 - \$100,000,000 Over \$100,000,000 X Decline to Disclose |
OR Aggregate Net Asset Value Range No Aggregate Net Asset Value \$1 - \$5,000,000 \$5,000,001 - \$25,000,000 \$25,000,001 - \$50,000,000 \$50,000,001 - \$100,000,000 Over \$100,000,000 Decline to Disclose |
| Not Applicable | Not Applicable |
| Rule 504(b)(1) (not (i), (ii) or (iii)) Rule 504 (b)(1)(i) Rule 504 (b)(1)(ii) Rule 504 (b)(1)(iii) |
6. Federal Exemption(s) and Exclusion(s) Claimed (select all that apply) Rule 505 X Rule 506(b) Rule 506(c) Securities Act Section 4(a)(5) Investment Company Act Section 3(c) |

| Section 3(c)(4) Section 3(c)(5) Section 3(c)(6) Section 3(c)(7) |
Section 3(c)(12) Section 3(c)(13) Section 3(c)(14) |
|---|---|
| 7. Type of Filing | |
| X New Notice Date of First Sale 2018-03-15 Amendment |
First Sale Yet to Occur |
| 8. Duration of Offering | |
| Does the Issuer intend this offering to last more than one year? | Yes X No |
| 9. Type(s) of Securities Offered (select all that apply) | |
| X Equity Debt Option, Warrant or Other Right to Acquire Another Security Security to be Acquired Upon Exercise of Option, Warrant or Other Right to Acquire Security |
Pooled Investment Fund Interests Tenant-in-Common Securities Mineral Property Securities Other (describe) |
| 10. Business Combination Transaction | |
| Is this offering being made in connection with a business combination transaction, such as a merger, acquisition or exchange offer? |
X Yes No |
| Clarification of Response (if Necessary): | |
| An aggregate 1,462,936 of Filer's ordinary shares were issued to 2 U.S. persons as part of an exchange offer to certain shareholders of the Filer's subsidiary TyrNovo, as disclosed by the Filer on Form 6-K furnished to the Commission on March 15, 2018. |
|
| 11. Minimum Investment | |
| Minimum investment accepted from any outside investor \$ 0 USD | |
| 12. Sales Compensation | |
| Recipient None |
Recipient CRD Number X None |
| (Associated) Broker or Dealer X None |
(Associated) Broker or Dealer CRD Number X None |
| Street Address 1 NONE NONE City State/Province/Country NONE UNKNOWN |
Street Address 2 ZIP/Postal Code 0000000 |
| State(s) of Solicitation All States Non-US/Foreign AL AK AZ AR X CA CO CT IL IN IA KS KY LA ME MT NE NV NH NJ NM NY RI SC SD TN X TX UT VT |
DE DC FL GA HI ID MD MA MI MN MS MO NC ND OH OK OR PA VA WA WV WI WY PR |
| 13. Offering and Sales Amounts | |
| Total Offering Amount \$ 0 USD or Total Amount Sold \$ 0 USD Total Remaining to be Sold \$ 0 USD or |
Indefinite Indefinite |
| 14. Investors | |
|---|---|
| X Select if securities in the offering have been or may be sold to persons who do not qualify as accredited investors, and enter the number of such non-accredited investors who already have invested in the offering. Regardless of whether securities in the offering have been or may be sold to persons who do not qualify as accredited investors, enter the total number of investors who already have invested in the offering: 15. Sales Commissions & Finder's Fees Expenses |
2 2 |
| Provide separately the amounts of sales commissions and finders fees expenses, if any. If the amount of an expenditure is not known, provide an estimate and check the box next to the amount. |
|
| Sales Commissions \$ 0 USD Estimate |
|
| Finders' Fees \$ 0 USD Estimate |
|
| Clarification of Response (if Necessary): | |
| 16. Use of Proceeds | |
| Provide the amount of the gross proceeds of the offering that has been or is proposed to be used for payments to any of the persons required to be named as executive officers, directors or promoters in response to Item 3 above. If the amount is unknown, provide an estimate and check the box next to the amount. |
| Signature and Submission | |
|---|---|
| Clarification of Response (if Necessary): | |
| \$ 0 USD Estimate |
|
| above. If the amount is unknown, provide an estimate and check the box next to the amount. |
Please verify the information you have entered and review the Terms of Submission below before signing and submitting this notice.
In submitting this notice, each identified issuer is:
Each Issuer identified above has read this notice, knows the contents to be true, and has duly caused this notice to be signed on its behalf by the undersigned duly authorized person.
For signature, type in the signer's name or other letters or characters adopted or authorized as the signer's signature.
| Issuer | Signature | Name of Signer |
Title | Date |
|---|---|---|---|---|
| Kitov Pharma Ltd. | /s/ Simcha Rock | Simcha Rock | Chief Financial Officer and Director | 2018-03-26 |
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 number.
* This undertaking does not affect any limits Section 102(a) of the National Securities Markets Improvement Act of 1996 ("NSMIA") [Pub. L. No. 104-290, 110 Stat. 3416 (Oct. 11, 1996)] imposes on the ability of States to require information. As a result, if the securities that are the subject of this Form D are "covered securities" for purposes of NSMIA, whether in all instances or due to the nature of the offering that is the subject of this Form D, States cannot routinely require offering materials under this undertaking or otherwise and can require offering materials only to the extent NSMIA permits them to do so under NSMIA's preservation of their anti-fraud authority.
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