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 GERON CORPORATION |
| 919 E. HILLSDALE BLVD, SUITE 250 |
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year)
03/01/2022
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3. Issuer Name and Ticker or Trading Symbol
Personalis, Inc.
[ PSNL ]
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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 |
|
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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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: |
| Remarks: |
|
| No securities are beneficially owned. |
|
/s/ Aaron Tachibana, Attorney-in-Fact |
03/01/2022 |
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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 by these presents, that the undersigned hereby
constitutes and appoints each of John West, Aaron Tachibana,
Stephen Moore, Michael Tenta, Allison Peth, Jacob Hanna
and Kristin Peardon, with full power of substitution,
signing individually, the undersigneds true and lawful
attorneys-in fact and agents to:
(1) execute for and on behalf of the undersigned,
in the undersigneds capacity as an officer, director
or beneficial owner of more than 10% of a registered
class of securities of Personalis, Inc., Forms 3, 4, and 5
(including any amendments thereto), relating to the
securities of Personalis, Inc., in accordance with
Section 16(a) of the Securities Exchange Act of 1934,
as amended (the "Exchange Act") and the rules thereunder
and a Form ID, Uniform Application for Access Codes to
File on EDGAR;
(2) do and perform any and all acts for and on
behalf of the undersigned that may be necessary or
desirable to execute such Forms 3, 4, or 5, or
Form ID (including any amendments thereto) and timely
file such forms with the United States Securities and
Exchange Commission and any stock exchange or
similar authority; and
(3) take any other action of any nature whatsoever
in connection with the foregoing which, in the opinion
of such attorney-in-fact, may be of benefit, 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-facts
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-facts 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 Personalis, Inc. assuming, any of the
undersigneds 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 undersigneds
holdings of and transactions in securities issued by
Personalis, Inc., (b) revocation by the undersigned
in a signed writing delivered to the foregoing
attorneys-in-fact or (c) as to any attorney-in-fact
individually, until such attorney-in-fact is no longer
employed by Personalis, Inc. or Cooley LLP.
The undersigned has caused this Power of Attorney to be
executed as of March 1, 2022.
/s/ Olivia Bloom
_________________________________
Signature
Olivia Bloom
Print Name
