Registration Form • May 16, 2020
Registration Form
Open in ViewerOpens in native device viewer
UNITED STATES SECURITIES AND EXCHANGE COMMISSION OMB APPROVAL
Washington, D.C. 20549 FORM D
OMB Number: 3235-0076 Estimated average burden hours per response 4.00
Notice of Exempt Offering of Securities
| 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 | ||||
| ISRAEL | Jurisdiction of Incorporation/Organization | X Other (Specify) | ||
| Year of Incorporation/Organization | Limited company | |||
| 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 | |||
| City | State/Province/Country | ZIP/PostalCode | Phone Number of Issuer | |
| TEL AVIV | ISRAEL | 6701101 | 97239333121 | |
| 3. Related Persons | ||||
| Last Name | First Name | Middle Name | ||
| Israel Street Address 1 |
Isaac | Street Address 2 | ||
| One Azrieli Center | Round Building | |||
| City | 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 | ||
| Rowinsky | Eric | |||
| Street Address 1 | Street Address 2 | |||
| One Azrieli Center | Round Building | |||
| City Tel Aviv |
ISRAEL | State/Province/Country | ZIP/PostalCode 6701101 |
|
| Relationship: | Executive Officer | X Director |
Promoter | |
| Clarification of Response (if Necessary): | ||||
| Independent Director and Chairman of the Board of Directors of the Issuer | ||||
| Last Name | First Name | Middle Name | ||
| Rock | Simcha | |||
| Street Address 1 | Street Address 2 | |||
| One Azrieli Center | Round Building | |||
| City | State/Province/Country | ZIP/PostalCode | ||
| Tel Aviv Relationship: |
ISRAEL Executive Officer |
X Director |
Promoter | 6701101 |
| Clarification of Response (if Necessary): | ||||
| Director of the Issuer | ||||
| Last Name | First Name | Middle Name | ||
| Steinberg | Steven |
| Street Address 1 One Azrieli Center City Tel Aviv Relationship: |
Executive Officer | Street Address 2 Round Building State/Province/Country ISRAEL X Director Promoter |
ZIP/PostalCode 6701101 |
|
|---|---|---|---|---|
| Clarification of Response (if Necessary): | ||||
| Independent Director of the Issuer | ||||
| Last Name | First Name | Middle Name | ||
| Agmon Street Address 1 One Azrieli Center City |
Ido Street Address 2 Round Building State/Province/Country |
ZIP/PostalCode | ||
| Tel Aviv Relationship: |
Executive Officer | ISRAEL X Director Promoter |
6701101 | |
| Clarification of Response (if Necessary): | ||||
| Independent Director of the Issuer | ||||
| Last Name | First Name | Middle Name | ||
| Tzror Street Address 1 |
Ran Street Address 2 |
|||
| One Azrieli Center City |
Round Building State/Province/Country |
ZIP/PostalCode | ||
| Tel Aviv | ISRAEL | 6701101 | ||
| Relationship: | Executive Officer | X Director Promoter |
||
| Independent Director of the Issuer | Clarification of Response (if Necessary): | |||
| Last Name Stern-Raff |
First Name Revital |
Middle Name | ||
| Street Address 1 One Azrieli Center |
Street Address 2 Round Building |
|||
| City | State/Province/Country | ZIP/PostalCode | ||
| Tel Aviv Relationship: |
Executive Officer | ISRAEL X Director Promoter |
6701101 | |
| Clarification of Response (if Necessary): | ||||
| Independent Director of the Issuer | ||||
| Last Name Ben-Menachem |
First Name Gil |
Middle Name | ||
| Street Address 1 | Street Address 2 | |||
| One Azrieli Center City |
||||
| Round Building | ||||
| Tel Aviv | State/Province/Country ISRAEL |
ZIP/PostalCode 6701101 |
||
| Relationship: | X Executive Officer |
Director Promoter |
||
| Clarification of Response (if Necessary): | ||||
| Vice President of Business Development of the Issuer | ||||
| Last Name | First Name | Middle Name | ||
| Reuveni Street Address 1 |
Hadas Street Address 2 |
|||
| One Azrieli Center | Round Building | |||
| City Tel Aviv |
State/Province/Country ISRAEL |
ZIP/PostalCode 6701101 |
||
| Relationship: | X Executive Officer |
Director Promoter |
||
| Clarification of Response (if Necessary): | ||||
| VP R&D of the Issuer | ||||
| Last Name | First Name | Middle Name | ||
| Efron Street Address 1 |
Gil Street Address 2 |
|||
| One Azrieli Center | Round Building | |||
| City Tel Aviv Relationship: |
X Executive Officer |
State/Province/Country ISRAEL Director Promoter |
ZIP/PostalCode 6701101 |
Clarification of Response (if Necessary):
\$25,000,001 -
| Deputy CEO and Chief Financial Officer of the Issuer | ||
|---|---|---|
| Last Name Liang Street Address 1 One Azrieli Center City Tel Aviv X Relationship: Executive Officer Clarification of Response (if Necessary): |
First Name Bertrand Street Address 2 Round Building State/Province/Country ISRAEL Director Promoter |
Middle Name ZIP/PostalCode 6701101 |
| Chief Medical Officer of the Issuer | ||
| Last Name Schickler Street Address 1 One Azrieli Center City Tel Aviv Relationship: X Executive Officer Clarification of Response (if Necessary): Head of Clinical Operations of the Issuer |
First Name Michael Street Address 2 Round Building State/Province/Country ISRAEL Director Promoter |
Middle Name ZIP/PostalCode 6701101 |
| 4. Industry Group | ||
| Agriculture Banking & Financial Services Commercial Banking Insurance Investing Investment Banking Pooled Investment Fund Is the issuer registered as an investment company under the Investment Company Act of 1940? Yes No Other Banking & Financial Services Business Services Energy Coal Mining Electric Utilities Energy Conservation Environmental Services Oil & Gas Other Energy |
Health Care Biotechnology Health Insurance Hospitals & Physicians X Pharmaceuticals Other Health Care Manufacturing Real Estate Commercial Construction REITS & Finance Residential Other Real Estate |
Retailing Restaurants Technology Computers Telecommunications Other Technology Travel Airlines & Airports Lodging & Conventions Tourism & Travel Services Other Travel Other |
| 5. Issuer Size | ||
| Revenue Range No Revenues \$1 - \$1,000,000 \$1,000,001 - \$5,000,000 \$5,000,001 - \$25,000,000 |
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 |
\$100,000,000 \$50,000,001 - \$100,000,000
Over \$100,000,000 Over \$100,000,000 X Decline to Disclose Decline to Disclose
| Not Applicable | Not Applicable | |
|---|---|---|
| ---------------- | -- | ---------------- |
| 6. Federal Exemption(s) and Exclusion(s) Claimed (select all that apply) |
|---|
| X Rule 506(b) Rule 504(b)(1) (not (i), (ii) or (iii)) Rule 504 (b)(1)(i) Rule 506(c) Rule 504 (b)(1)(ii) Securities Act Section 4(a)(5) Rule 504 (b)(1)(iii) Investment Company Act Section 3(c) Section 3(c)(1) Section 3(c)(9) Section 3(c)(2) Section 3(c)(10) Section 3(c)(3) Section 3(c)(11) Section 3(c)(4) Section 3(c)(12) Section 3(c)(5) Section 3(c)(13) Section 3(c)(6) Section 3(c)(14) Section 3(c)(7) |
| 7. Type of Filing |
| X New Notice Date of First Sale 2020-05-06 First Sale Yet to Occur Amendment |
| 8. Duration of Offering |
| X No Does the Issuer intend this offering to last more than one year? Yes |
| 9. Type(s) of Securities Offered (select all that apply) |
| Equity Pooled Investment Fund Interests Debt Tenant-in-Common Securities X Option, Warrant or Other Right to Acquire Another Security Mineral Property Securities X Security to be Acquired Upon Exercise of Option, Warrant or Other (describe) Other Right to Acquire Security |
| 10. Business Combination Transaction |
| Is this offering being made in connection with a business combination transaction, such as a Yes X No merger, acquisition or exchange offer? Clarification of Response (if Necessary): |
| 11. Minimum Investment |
| Minimum investment accepted from any outside investor \$ 0 USD |
| 12. Sales Compensation |
| Recipient Recipient CRD Number None H.C. Wainwright & Co., LLC 375 X None X None (Associated) Broker or Dealer (Associated) Broker or Dealer CRD Number |
| Street Address 1 Street Address 2 430 PARK AVENUE 3RD FLOOR City State/Province/Country ZIP/Postal Code NEW YORK NEW YORK 10022 State(s) of Solicitation All States Non-US/Foreign AL AK AZ AR X CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH X NJ NM X NY NC ND OH OK OR PA |
RI SC SD TN TX UT VT VA WA WV WI WY PR
| 13. Offering and Sales Amounts | ||||
|---|---|---|---|---|
| Total Offering Amount | \$ 10,000,001 | USD | or | Indefinite |
| Total Amount Sold | \$ 10,000,001 | USD | ||
| Total Remaining to be Sold | \$ 0 | USD | or | Indefinite |
| Clarification of Response (if Necessary): | ||||
| Represents the aggregate amount received from investors in connection with Issuer's registered offering of ADSs and concurrent private placement of warrants, respectively, which were issued jointly to investors for a single purchase price. |
||||
| 14. Investors | ||||
| invested in the offering. | 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 3 |
|||
| 15. Sales Commissions & Finder's Fees Expenses | ||||
| expenditure is not known, provide an estimate and check the box next to the amount. | Provide separately the amounts of sales commissions and finders fees expenses, if any. If the amount of an | |||
| \$ 700,000 USD Sales Commissions |
X Estimate | |||
| \$ 0 Finders' Fees |
USD Estimate |
|||
| Clarification of Response (if Necessary): | ||||
| up to 1,750,000 | Represents 7% commission of gross proceeds from investors for sale of ADSs in the registered offering and concurrent private placement of warrants. We also paid or reimbursed expenses of \$62,900 and issued unregistered warrants to purchase |
|||
| 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. |
||||
| \$ 0 USD | Estimate | |||
| Clarification of Response (if Necessary): | ||||
| Signature and Submission | ||||
| and submitting this notice. | Please verify the information you have entered and review the Terms of Submission below before signing | |||
| Terms of Submission | ||||
| In submitting this notice, each identified issuer is: | ||||
| furnished to offerees.* | • Notifying the SEC and/or each State in which this notice is filed of the offering of securities described and undertaking to furnish them, upon written request, in the accordance with applicable law, the information • Irrevocably appointing each of the Secretary of the SEC and the Securities Administrator or other legally designated officer of the State in which the issuer maintains its principal place of business and any State in |
which this notice is filed, as its agents for service of process, and agreeing that these persons may accept service on its behalf, of any notice, process or pleading, and further agreeing that such service may be made by registered or certified mail, in any Federal or state action, administrative proceeding, or arbitration brought against the issuer in any place subject to the jurisdiction of the United States, if the action, proceeding or arbitration (a) arises out of any activity in connection with the offering of securities that is the subject of this notice, and (b) is founded, directly or indirectly, upon the provisions of: (i) the Securities Act of 1933, the Securities Exchange Act of 1934, the Trust Indenture Act of 1939, the Investment Company Act of 1940, or the Investment Advisers Act of 1940, or any rule or regulation under any of these statutes; or (ii) the laws of the State in which the issuer maintains its principal place of business or any State in which this notice is filed.
•
Certifying that, if the issuer is claiming a Regulation D exemption for the offering, the issuer is not disqualified from relying on Rule 504 or Rule 506 for one of the reasons stated in Rule 504(b)(3) or Rule 506 (d).
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/ Gil Efron | Gil Efron | Deputy CEO and Chief Financial Officer |
2020-05-15 |
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.
Building tools?
Free accounts include 100 API calls/year for testing.
Have a question? We'll get back to you promptly.