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 | ||||
Director Stock Option (Right to Buy) | Â (4) | 01/28/2015 | Common Stock | 4,800 | $ 6 | D | Â |
Common Stock Warrants (Right to Buy) | Â (5) | 07/30/2009 | Common Stock | 200,000 | $ 5 | I | By Kona MN, LLC (3) |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
Hauser Richard J 50 S. 6TH STREET, SUITE 1480 MINNEAPOLIS, MN 55402 |
 X |  |  |  |
Mark S. Robinow, as attorney-in-fact | 08/15/2005 | |
**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) | Assumes the conversion of shares of the Issuer's Series A Convertible Preferred Stock into shares of the Issuer's Common Stock on a 1-for-5 basis immediately prior to the closing of the Issuer's initial public offering. |
(2) | Assumes the conversion of all principal amounts outstanding under the Issuer's convertible subordinated promissory note into shares of the Issuer's Series B Convertible Preferred Stock, and the conversion of such shares of the Issuer's Series B Convertible Preferred Stock into 500,000 shares of the Issuer's Common Stock, immediately prior to the closing of the Issuer's initial public offering. |
(3) | The shares are held by Kona MN, LLC, of which the reporting person is a control person. |
(4) | The option is fully vested and exercisable. |
(5) | The warrant is exercisable immediately. |