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 ADVENT INTERNATIONAL CORPORATION |
75 STATE STREET, 29TH FLOOR |
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year) 04/27/2017
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3. Issuer Name and Ticker or Trading Symbol
NCS Multistage Holdings, Inc.
[ NCSM ]
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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 |
30,943,536
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I |
See Notes
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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 |
1. Name and Address of Reporting Person*
C/O ADVENT INTERNATIONAL CORPORATION |
75 STATE STREET, 29TH FLOOR |
(Street)
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1. Name and Address of Reporting Person*
C/O ADVENT INTERNATIONAL CORPORATION |
75 STATE STREET, 29TH FLOOR |
(Street)
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1. Name and Address of Reporting Person*
C/O ADVENT INTERNATIONAL CORPORATION |
75 STATE STREET, 29TH FLOOR |
(Street)
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1. Name and Address of Reporting Person*
C/O ADVENT INTERNATIONAL CORPORATION |
75 STATE STREET, 29TH FLOOR |
(Street)
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1. Name and Address of Reporting Person*
C/O ADVENT INTERNATIONAL CORPORATION |
75 STATE STREET, 29TH FLOOR |
(Street)
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1. Name and Address of Reporting Person*
C/O ADVENT INTERNATIONAL CORPORATION |
75 STATE STREET, 29TH FLOOR |
(Street)
|
1. Name and Address of Reporting Person*
C/O ADVENT INTERNATIONAL CORPORATION |
75 STATE STREET, 29TH FLOOR |
(Street)
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1. Name and Address of Reporting Person*
C/O ADVENT INTERNATIONAL CORPORATION |
75 STATE STREET, 29TH FLOOR |
(Street)
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1. Name and Address of Reporting Person*
C/O ADVENT INTERNATIONAL CORPORATION |
75 STATE STREET, 29TH FLOOR |
(Street)
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Explanation of Responses: |
Remarks: |
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/s/ Richard Terranova, Attorney-in-Fact |
04/27/2017 |
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/s/ Richard Terranova, Attorney-in-Fact |
04/27/2017 |
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/s/ Richard Terranova, Attorney-in-Fact |
04/27/2017 |
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/s/ Richard Terranova, Attorney-in-Fact |
04/27/2017 |
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/s/ Richard Terranova, Attorney-in-Fact |
04/27/2017 |
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/s/ Richard Terranova, Attorney-in-Fact |
04/27/2017 |
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/s/ Richard Terranova, Attorney-in-Fact |
04/27/2017 |
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/s/ Richard Terranova, Attorney-in-Fact |
04/27/2017 |
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/s/ Richard Terranova, Attorney-in-Fact |
04/27/2017 |
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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
KNOW ALL PEOPLE BY THESE PRESENTS that Advent International Corporation, a
Delaware corporation with its principal place of business at 75 State Street,
Boston, Massachusetts ("Advent"), hereby constitutes and appoints Richard
Terranova (the "Attorney") as Advent's true and lawful attorney in its name and
stead to execute and file on behalf of the Corporation in its corporate
capacity and on behalf of the Corporation in its capacity as manager or general
partner of any limited partnership or other entity managed directly or
indirectly by the Corporation any (i) voting proxies and similar documents and
(ii) federal, state, local and foreign filings required to be made to any
governmental, regulatory or similar authority in connection with legal or
regulatory matters, including but not limited to filings with the United States
Securities and Exchange Commission and any "blue sky" or similar state
regulatory filings, in each case provided such action or document has been
approved by a member of the Corporation's legal or compliance department.
This Power of Attorney and the power and authority granted to the Attorney
hereunder shall automatically terminate, without any further action on the part
of Advent or the Attorney, on December 31, 2018, unless otherwise terminated
earlier by Advent at any time in its sole discretion.
IN WITNESS WHEREOF, Advent has set its hand and seal this 1st of January 2017.
ADVENT INTERNATIONAL CORPORATION
By: /s/ Andrew Dodge
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Name: Andrew Dodge
Title: Vice President