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 VACCINEX, INC. |
| 1895 MOUNT HOPE AVENUE |
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year)
05/11/2021
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3. Issuer Name and Ticker or Trading Symbol
VACCINEX, INC.
[ VCNX ]
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
|
Director |
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10% Owner |
| X |
Officer (give title below) |
|
Other (specify below) |
| Chief Operating Officer |
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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)
| X |
Form filed by One Reporting Person |
|
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)
|
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 |
9,600 |
D |
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Table II - Derivative Securities Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
|
|---|
| 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 |
| Stock Option (Right to Buy) |
|
12/22/2025 |
Common Stock |
9,610 |
7.1 |
D |
|
| Stock Option (Right to Buy) |
|
12/23/2025 |
Common Stock |
8,605 |
7.1 |
D |
|
| Stock Option (Right to Buy) |
|
03/14/2029 |
Common Stock |
12,400 |
3.9 |
D |
|
| Stock Option (Right to Buy) |
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04/04/2030 |
Common Stock |
10,000 |
3.82 |
D |
|
| Stock Option (Right to Buy) |
|
04/03/2031 |
Common Stock |
8,000 |
2.93 |
D |
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| Explanation of Responses: |
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/s/ Scott E. Royer, Attorney-in-Fact for Elizabeth Evans |
05/21/2021 |
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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. |
VACCINEX, INC.
SECTION 16
POWER OF ATTORNEY
Know all by these presents, that the undersigned hereby
constitutes and appoints each of Maurice Zauderer and Scott
E. Royer, each for so long as she is an officer of
Vaccinex, Inc. (the "Company"), the undersigned's true and
lawful attorney-in-fact to:
(1) execute for and on behalf of the undersigned, in
the undersigned's capacity as an officerand/or director of
the Company, Forms 3, 4 and 5 in accordance with Section
16(a) of the Securities Exchange Act of 1934, as amended,
and the rules thereunder;
(2) do and perform any and all acts for and on behalf of the
undersigned which may be necessary or desirable to complete
and execute any such Form 3, 4, or 5 and timely file such
form with the United States Securities and Exchange Commission
and any stock exchange or similar authority; and
(3) take any other action of any type whatsoever in connection
with the foregoing which, in the opinion of such attorney-in-
fact, may be of benefit to, in the best interest of, or
legally required by, the undersigned, it being understood that
the documents executed by such attorney-in-fact on behalf of
the undersigned pursuant to this Power of Attorney shall be in
such form and shall contain such terms and conditions as such
attorney-in-fact may approve in such attorney-in-fact's
discretion.
The undersigned hereby grants to each attorney-in-fact
full power and authority to do and perform any and every act
and thing whatsoever requisite, necessary, or proper to be
done in the exercise of any of the rights and powers herein
granted, as fully to all intents and purposes as the
undersigned could do if personally present, with full power of
substitution or revocation, hereby ratifying and confirming all
that such attorney-in-fact, or such attorney-in-fact's
substitute or substitutes, shall lawfully do or cause to be
done by virtue of this Power of Attorney and the rights and
powers herein granted. The undersigned acknowledges that the
foregoing attorneys-in-fact, in serving in such capacity at the
request of the undersigned, are not assuming, nor is the Company
assuming, any of the undersigned's responsibilities to comply
with Section 16 of the Securities Exchange Act of 1934, as
amended.
This Power of Attorney shall remain in full force and effect
until the undersigned is no longer required to file Forms 3, 4
and 5 with respect to the undersigned's holdings of and
transactions in securities issued by the Company, unless earlier
revoked by the undersigned in a signed writing to the foregoing
attorneys-in-fact.
IN WITNESS WHEREOF, the undersigned has caused this Power of
Attorney to be executed as of this 14th day of May, 2021.
/s/ Elizabeth Evans
Elizabeth Evans
