SEC FORM
3
SEC Form 3
FORM 3 |
UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549
INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES
Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934 or Section 30(h) of the Investment Company Act of 1940
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OMB APPROVAL |
OMB Number: |
3235-0104 |
Estimated average burden |
hours per response: |
0.5 |
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1. Name and Address of Reporting Person*
C/O NEW LEAF VENTURES |
TIMES SQUARE TOWER, 7 TIMES SQ, STE 3502 |
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year) 12/18/2012
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3. Issuer Name and Ticker or Trading Symbol
MEI Pharma, Inc.
[ MEIP ]
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
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Director |
X |
10% Owner |
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Officer (give title below) |
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Other (specify below) |
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5. If Amendment, Date of Original Filed
(Month/Day/Year)
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6. Individual or Joint/Group Filing (Check Applicable Line)
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Form filed by One Reporting Person |
X |
Form filed by More than One Reporting Person |
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Table I - Non-Derivative Securities Beneficially Owned |
1. Title of Security (Instr.
4)
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2.
Amount of Securities Beneficially Owned (Instr.
4)
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3. Ownership Form: Direct (D) or Indirect (I) (Instr.
5)
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4. Nature of Indirect Beneficial Ownership (Instr.
5)
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Common Stock |
3,000,000 |
D
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Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities)
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1. Title of Derivative Security (Instr.
4)
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2. Date Exercisable and Expiration Date
(Month/Day/Year) |
3. Title and Amount of Securities Underlying Derivative Security (Instr.
4)
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4. Conversion or Exercise Price of Derivative Security
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5. Ownership Form: Direct (D) or Indirect (I) (Instr.
5)
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6. Nature of Indirect Beneficial Ownership (Instr.
5)
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Date Exercisable |
Expiration Date |
Title |
Amount or Number of Shares |
Warrants |
12/18/2012 |
12/18/2017 |
Common Stock |
2,100,000 |
3.12 |
D
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1. Name and Address of Reporting Person*
C/O NEW LEAF VENTURES |
TIMES SQUARE TOWER, 7 TIMES SQ, STE 3502 |
(Street)
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1. Name and Address of Reporting Person*
C/O NEW LEAF VENTURES |
TIMES SQUARE TOWER, 7 TIMES SQ, STE 3502 |
(Street)
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1. Name and Address of Reporting Person*
C/O NEW LEAF VENTURES |
TIMES SQUARE TOWER, 7 TIMES SQ, STE 3502 |
(Street)
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1. Name and Address of Reporting Person*
C/O NEW LEAF VENTURES |
TIMES SQUARE TOWER, 7 TIMES SQ, STE 3502 |
(Street)
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1. Name and Address of Reporting Person*
C/O NEW LEAF VENTURES |
TIMES SQUARE TOWER, 7 TIMES SQ, STE 3502 |
(Street)
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1. Name and Address of Reporting Person*
C/O NEW LEAF VENTURES |
TIMES SQUARE TOWER, 7 TIMES SQ, STE 3502 |
(Street)
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1. Name and Address of Reporting Person*
C/O NEW LEAF VENTURES |
2500 SAND HILL ROAD, SUITE 203 |
(Street)
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1. Name and Address of Reporting Person*
C/O NEW LEAF VENTURES |
2500 SAND HILL ROAD, SUITE 203 |
(Street)
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1. Name and Address of Reporting Person*
C/O NEW LEAF VENTURES |
2500 SAND HILL ROAD, SUITE 203 |
(Street)
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Explanation of Responses: |
Remarks: |
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/s/ Craig L. Slutzkin, Chief Financial Officer of New Leaf Venture Management II, L.L.C., the sole general partner of New Leaf Venture Associates II, L.P., the sole general partner of New Leaf Ventures II, L.P. |
12/28/2012 |
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/s/ Craig L. Slutzkin, Chief Financial Officer of New Leaf Venture Management II, L.L.C., the sole general partner of New Leaf Venture Associates II, L.P. |
12/28/2012 |
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/s/ Craig L. Slutzkin, Chief Financial Officer of New Leaf Venture Management II, L.L.C. |
12/28/2012 |
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/s/ Craig L. Slutzkin, as Attorney-in-Fact for Philippe O. Chambon |
12/28/2012 |
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/s/ Craig L. Slutzkin, as Attorney-in-Fact for James Niedel |
12/28/2012 |
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/s/ Craig L. Slutzkin, as Attorney-in-Fact for Ronald Hunt |
12/28/2012 |
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/s/ Craig L. Slutzkin, as Attorney-in-Fact for Vijay Lathi |
12/28/2012 |
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/s/ Craig L. Slutzkin, as Attorney-in-Fact for Jeani Delagardelle |
12/28/2012 |
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/s/ Craig L. Slutzkin, as Attorney-in-Fact for Srinivas Akkaraju |
12/28/2012 |
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** Signature of Reporting Person |
Date |
Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. |
* 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). |
Note: File three copies of this Form, one of which must be manually signed. If space is insufficient,
see
Instruction 6 for procedure. |
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. |
POWER OF ATTORNEY
KNOWN ALL MEN BY THESE PRESENTS, that the undersigned hereby constitutes and appoints CRAIG
L. SLUTZKIN as his true and lawful attorney-in-fact and agent for him and in his name, place
and stead, in any and all capacities, to sign any and all documents relating to any and all
Securities and Exchange Commission filings which may be required, granting unto said
attorney-in-fact and agent full power and authority to do and perform each and every act and
thing requisite and necessary to be done in and about the premises, as fully to all intents
and purposes as he might or could do in person, thereby ratifying and confirming all that said
attorney-in-fact may lawfully do or cause to be done by virtue hereof.
This power shall continue in effect until terminated in writing.
By: /s/ Vijay K. Lathi
Vijay K. Lathi
By: /s/ James Niedel
James Niedel
Dated: October 5, 2005
POWER OF ATTORNEY
KNOWN ALL MEN BY THESE PRESENTS, that the undersigned hereby constitutes and appoints CRAIG
L. SLUTZKIN as his/her true and lawful attorney-in-fact and agent for him/her and in his/her
name, place and stead, in any and all capacities, to sign any and all documents relating to
any and all Securities and Exchange Commission filings which may be required, granting unto
said attorney-in-fact and agent full power and authority to do and perform each and every act
and thing requisite and necessary to be done in and about the premises, as fully to all
intents and purposes as he/she might or could do in person, thereby ratifying and confirming
all that said attorney-in-fact may lawfully do or cause to be done by virtue hereof.
This power shall continue in effect until terminated in writing.
By: /s/ Philippe O. Chambon
Philippe O. Chambon
By: /s/ Jeani Delagardelle
Jeani Delagardelle
By: /s/ Ronald Hunt
Ronald Hunt
Dated: September 29, 2006
POWER OF ATTORNEY
KNOWN ALL MEN BY THESE PRESENTS, that the undersigned hereby constitutes and appoints CRAIG
L. SLUTZKIN as his true and lawful attorney-in-fact and agent for him and in his name, place
and stead, in any and all capacities, to sign any and all documents relating to any and all
Securities and Exchange Commission filings which may be required, granting unto said
attorney-in-fact and agent full power and authority to do and perform each and every act and
thing requisite and necessary to be done in and about the premises, as fully to all intents
and purposes as he might or could do in person, thereby ratifying and confirming all that
said attorney-in-fact may lawfully do or cause to be done by virtue hereof.
This power shall continue in effect until terminated in writing.
By: /s/ Srinivas Akkaraju
Srinivas Akkaraju
Dated: February 2, 2009