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
|
| OMB APPROVAL |
| OMB Number: |
3235-0104 |
| Estimated average burden |
| hours per response: |
0.5 |
|
|
1. Name and Address of Reporting Person*
| 7529 STANDISH PLACE |
| SUITE 200 |
(Street)
|
2. Date of Event Requiring Statement
(Month/Day/Year)
06/29/2021
|
3. Issuer Name and Ticker or Trading Symbol
Xometry, Inc.
[ XMTR ]
|
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
|
Director |
|
10% Owner |
| X |
Officer (give title below) |
|
Other (specify below) |
| Chief Financial Officer |
|
5. If Amendment, Date of Original Filed
(Month/Day/Year)
|
6. Individual or Joint/Group Filing (Check Applicable Line)
| X |
Form filed by One Reporting Person |
|
Form filed by More than One Reporting Person |
|
| Table I - Non-Derivative Securities Beneficially Owned |
|---|
| 1. Title of Security (Instr.
4)
|
2.
Amount of Securities Beneficially Owned (Instr.
4)
|
3. Ownership Form: Direct (D) or Indirect (I) (Instr.
5)
|
4. Nature of Indirect Beneficial Ownership (Instr.
5)
|
Table II - Derivative Securities Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
|
|---|
| 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: Direct (D) or Indirect (I) (Instr.
5)
|
6. Nature of Indirect Beneficial Ownership (Instr.
5)
|
| Date Exercisable |
Expiration Date |
Title |
Amount or Number of Shares |
| Stock Option (right to buy) |
|
05/05/2030 |
Common Stock |
458,822 |
3.65 |
D |
|
| Stock Option (right to buy) |
|
03/27/2031 |
Common Stock |
10,000 |
12.32 |
D |
|
| Explanation of Responses: |
|
|
| Remarks: |
|
|
/s/ Dorothy Vinsky, Attorney-in-Fact |
07/08/2021 |
|
** 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
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 ofbenefit 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 ofAttorney
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 ifpersonally 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 ofAttorney 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 ofAttorney to be
executed as of June 24 , 2021.
By: /s/ James Michael Rallo
Print Name: James Michael Rallo
2
Signature ofAuthorized Person: /s/ James Michael Rallo
Printed Name of Signature: James Michael Rallo
Chief Financial Officer
Title of Person Signing:
Notary Signature & Seal to be Placed Here: /s/ Minta Beatrice Brown
06/ 24/ 2021
Minta Beatrice Brown
REGISTRATION NUMBER
7585484
COMMISSION EXPIRES
July 31 , 2022
Electronic Notary Public
Notarized online using audio-video communication
Henrico Virginia
3
