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 ALPHA TEKNOVA, INC. |
2451 BERT DRIVE |
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year) 08/31/2023
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3. Issuer Name and Ticker or Trading Symbol
Alpha Teknova, Inc.
[ TKNO ]
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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 |
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 |
Explanation of Responses: |
No securities are beneficially owned. |
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By: Damon A. Terrill For: Martha J. Demski |
08/31/2023 |
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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. |
LIMITED POWER OF ATTORNEY
1. Know all by these present that the undersigned hereby constitutes and
appoints each of Stephen Gunstream and Damon Terrill (each, an
"Attorney in fact") of Alpha Teknova, Inc. (the "Company"), or either of
them acting singly and with full power of substitution, as the undersigned's
true and lawful attorney in fact to, if and as applicable:
2. submit to the U.S. Securities and Exchange Commission (the "SEC") a
Form ID Application Acknowledgement on the Electronic Data Gathering,
Analysis, and Retrieval system (EDGAR) of the SEC, including any amendments
thereto, and any other documents necessary or appropriate to obtain EDGAR
codes and passwords enabling the undersigned to make electronic filings with
the SEC of reports required by Sections 13(d), 13(g), or Section 16(a) of the
Securities Exchange Act of 1934, as amended (the "Exchange Act"), or any
other rule or regulation of the SEC.
3. prepare, submit, execute for, and on behalf of the undersigned, in the
undersigned's capacity as an officer, director, and or holder of 10% or more
of a registered class of securities, as applicable, of the Company (a)
Schedules 13D and 13G (and any amendments thereto) in accordance with Sections
13(d) and l 3(g) of the Exchange Act and the rules promulgated thereunder,
(b) Forms 3, 4, and 5 (and any amendments thereto) in accordance with Section
16(a) of the Exchange Act and the rules promulgated thereunder, and (c) any
other forms or reports the undersigned may be required to file in connection
with the undersigned's ownership, acquisition, or disposition of securities
of the Company;
4. do and perform any and all acts for and on behalf of the undersigned that
may be necessary or desirable to prepare, complete, and execute any such
Schedule 13D, Schedule 130, Form 3, 4, or 5, or other form or report (or any
amendment thereto), and timely file such schedule, form, or report with the
SEC and any stock exchange or similar authority, including, but not limited
to, obtaining passphrases and access codes from the SEC on the undersigned's
behalf;
5. seek or obtain, as the undersigned's representative and on the
undersigned's behalf, information on transactions in the Company's securities
from any broker or financial institution, and the undersigned hereby
authorizes any such person to release any such information to each of the
Attorneys in fact and approves and ratifies any such release of information;
and
6. 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 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.
7. 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 such
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 each
Attorney in fact, in serving in such capacities at the request of the
undersigned, is not assuming any of the undersigned's responsibilities to
comply with Section 13 or Section 16 of the Exchange Act.
8. This Power of Attorney, with respect to each of the Attorneys in fact,
shall remain in full force and effect until the earlier of (a) the date that
the undersigned is no longer required to file Schedules 13D and 13G and
Forms 3, 4, and 5 with respect to the undersigned's beneficial ownership and
transactions in securities issued by the Company, (b) with respect to the
Attorney in fact, this Power of Attorney is revoked by the undersigned in a
signed writing delivered to such Attorney in fact, or (c) the time at which
such attorney in fact is no longer employed by the Company or any of its
subsidiaries.
IN WITNESS WHEREOF, the undersigned has executed this Limited Power of
Attorney with effect as of the 31st day of August 2023.
Signed and acknowledged:
By: /s/ Martha J. Demski
Name & Title: Martha J. Demski, Director