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*
| 7529 STANDISH PLACE |
| SUITE 200 |
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year)
06/29/2021
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3. Issuer Name and Ticker or Trading Symbol
Xometry, Inc.
[ XMTR ]
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
| X |
Director |
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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)
| X |
Form filed by One Reporting Person |
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Form filed by More than One Reporting Person |
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| Table I - Non-Derivative Securities Beneficially Owned |
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| 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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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 |
| Stock Option (right to buy) |
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10/06/2030 |
Common Stock |
70,000 |
4.46 |
D |
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| Explanation of Responses: |
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| Remarks: |
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/s/ Dorothy Vinsky, Attorney-in-Fact |
06/29/2021 |
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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. |
POWER OF ATTORNEY
(For Executing Form ID and Forms 3, 4 and 5)
Know all by these presents, that the undersigned hereby
constitutes and appoints each of Sam Lipson, Dennis Craig II and
Dorothy Vinsky of Cooley LLP, and Kristie Scott and James Rallo
of Xometry, Inc. (the "Company"), signing individually, the
undersigned's true and lawful attorneys-in-fact and agents to:
(1) Prepare, execute in the undersigned's name and on the
undersigned's behalf, and submit to the Securities and Exchange
Commission (the "SEC"), a Form ID and Forms 3, 4 and 5
(including amendments thereto and joint filing agreements in
connection therewith) in accordance with Section 16 of the
Securities Exchange Act of 1934, as amended (the "Exchange
Act"), and the rules thereunder, in the undersigned's capacity
as an officer, director or beneficial owner of more than 10% of
a registered class of securities of the Company;
(2) Do and perform any and all acts for and on behalf of
the undersigned that may be necessary or desirable to prepare
and execute any such Form ID and Forms 3, 4 or 5 (including
amendments thereto and joint filing agreements in connection
therewith) and file such forms with the SEC and any stock
exchange, self-regulatory association or any similar authority;
and
(3) Take any other action of any type whatsoever in
connection with the foregoing that, in the opinion of such
attorney-in-fact, may be of benefit to, in the best interest of,
or legally required of the undersigned, it being understood that
the documents executed by the 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 the
attorney-in-fact may approve in the attorney-in-fact's
discretion.
The undersigned hereby grants to each such 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 might or
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, and their substitutes, 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 Exchange Act.
This Power of Attorney shall remain in full force and
effect until the earliest to occur of (a) 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, (b) revocation by the undersigned in a signed
writing delivered to the Company and the foregoing attorneys-in
fact or (c) as to any attorney-in-fact individually, until such
attorney-in-fact is no longer employed by the Company or
employed by or a partner at Cooley LLP or another law firm
representing the Company, as applicable.
IN WITNESS WHEREOF, the undersigned has caused this Power
of Attorney to be executed as of June 7, 2021.
By: _/s/ Deborah Bial___________________
Deborah Bial
Signature Page to Power of Attorney (For Executing Form ID and Forms 3, 4 and 5)
