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 | ||||
Series B Preferred Stock | Â (4) | Â (4) | Common Stock | 215,548 (4) | $ (4) | I (1) | By DCM III, L.P. (1) |
Series B Preferred Stock | Â (4) | Â (4) | Common Stock | 5,711 (4) | $ (4) | I (2) | By DCM III-A, L.P. (2) |
Series B Preferred Stock | Â (4) | Â (4) | Common Stock | 10,531 (4) | $ (4) | I (3) | By DCM Affiliates Fund III, L.P. (3) |
Series E Preferred Stock | Â (5) | Â (5) | Common Stock | 877,834 (5) | $ (5) | I (1) | By DCM III, L.P. (1) |
Series E Preferred Stock | Â (5) | Â (5) | Common Stock | 23,258 (5) | $ (5) | I (2) | By DCM III-A, L.P. (2) |
Series E Preferred Stock | Â (5) | Â (5) | Common Stock | 42,890 (5) | $ (5) | I (3) | By DCM Affiliates Fund III, L.P. (3) |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
Blaisdell Thomas B C/O DCM INVESTMENT MANAGEMENT III, LLC 2420 SAND HILL ROAD, SUITE 200 MENLO PARK, CA 94025 |
 X |  X |  |  |
DCM Affiliates Fund III, L.P. 2420 SAND HILL ROAD SUITE 200 MENLO PARK, CA 94025 |
 |  X |  |  |
DCM III, L.P. 2420 SAND HILL ROAD SUITE 200 MENLO PARK, CA 94025 |
 |  X |  |  |
DCM III-A, L.P. 2420 SAND HILL ROAD SUITE 200 MENLO PARK, CA 94025 |
 |  X |  |  |
DCM Investment Management III, LLC 2420 SAND HILL ROAD SUITE 200 MENLO PARK, CA 94025 |
 |  X |  |  |
/s/ Jason R. Wisniewski, as Attorney in Fact for Thomas B. Blaisdell | 08/07/2007 | |
**Signature of Reporting Person | Date | |
/s/ Jason R. Wisniewski, as Attorney in Fact for DCM Affiliates Fund III, L.P. | 08/07/2007 | |
**Signature of Reporting Person | Date | |
/s/ Jason R. Wisniewski, as Attorney in Fact for DCM III, L.P. | 08/07/2007 | |
**Signature of Reporting Person | Date | |
/s/ Jason R. Wisniewski, as Attorney in Fact for DCM III-A, L.P. | 08/07/2007 | |
**Signature of Reporting Person | Date | |
/s/ Jason R. Wisniewski, as Attorney in Fact for DCM Investment Management III, LLC | 08/07/2007 | |
**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) | These securities are owned solely by DCM III, L.P., who may be deemed to be a a member of a "group" pursuant to Section 13(d) of the Exchange Act with DCM III-A, L.P and DCM Affiliates Fund III, L.P (collectively, the "DCM Funds"). DCM Investment Management, LLC ("DCM Management") is the general partner of each of the DCM Funds, and may be deemed to be an indirect beneficial owner of the securities. Thomas Blaisdell is a member of DCM Management and may be deemed to be an indirect beneficial owner of the securities. DCM Management and Mr. Blaisdell each disclaim beneficial ownership of the reported securities, except to the extent of any pecuniary interest therein. This report shall not be deemed an admission that any of the reporting persons is the beneficial owner of such securities for purposes of Section 16 or for any other purpose. |
(2) | These securities are owned solely by DCM III-A, L.P., who may be deemed to be a a member of a "group" pursuant to Section 13(d) of the Exchange Act with the other DCM Funds. DCM Management and Mr. Blaisdell may be deemed to be indirect beneficial owners of the securities. DCM Management and Mr. Blaisdell each disclaim beneficial ownership of the reported securities, except to the extent of any pecuniary interest therein. This report shall not be deemed an admission that any of the reporting persons is the beneficial owner of such securities for purposes of Section 16 or for any other purpose. |
(3) | These securities are owned solely by DCM Affiliates Fund III, L.P., who may be deemed to be a member of a "group" pursuant to Section 13(d) of the Exchange Act with the other DCM Funds. DCM Management and Mr. Blaisdell may be deemed to be indirect beneficial owners of the securities. DCM Management and Mr. Blaisdell each disclaim beneficial ownership of the reported securities, except to the extent of any pecuniary interest therein. This report shall not be deemed an admission that any of the reporting persons is the beneficial owner of such securities for purposes of Section 16 or for any other purpose. |
(4) | The Series B Preferred Stock is immediately convertible into HireRight, Inc. common stock and has no expiration date. Effective upon the closing of the issuer's initial public offering of common stock, the Series B Preferred Stock will automatically convert into the number of shares of common stock of HireRight, Inc. indicated in column 3. |
(5) | The Series E Preferred Stock is immediately convertible into HireRight, Inc. common stock and has no expiration date. Effective upon the closing of the issuer's initial public offering of common stock, the Series E Preferred Stock will automatically convert into the number of shares of common stock of HireRight, Inc. indicated in column 3. |