Specialized Disclosure Report (sd)
May 31 2017 - 3:51PM
Edgar (US Regulatory)
UNITED STATES
SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
FORM SD
SPECIALIZED DISCLOSURE REPORT
ENTELLUS
MEDICAL, INC.
(Exact name of registrant as specified in its charter)
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Delaware
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001-36814
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20-4627978
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(State or other jurisdiction
of incorporation)
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(Commission
File Number)
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(I.R.S. Employer
Identification No.)
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3600 Holly Lane North, Suite 40
Plymouth, Minnesota
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55447
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(Address of principal executive offices)
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(Zip Code)
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Jonelle R. Burnham
Vice President, General Counsel and Compliance Officer
(763) 463-1595
(Name and
telephone number, including area code, of the person to contact in connection with this report)
Check the appropriate box to
indicate the rule pursuant to which this form is being filed, and provide the period to which the information in this form applies:
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☒
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Rule 13p-1 under the Securities Exchange Act (17 CFR 230.13p-1) for the reporting period from January 1 to December 31, 2016.
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Item 1.01. Conflict Minerals Disclosure and Report
Conflict Minerals Disclosure
Entellus
Medical, Inc. has evaluated the products that Entellus and its subsidiary manufacture or contract to manufacture and has determined that certain products contain certain “conflict minerals,” which, for purposes of this specialized
disclosure report on Form SD, mean columbite-tantalite (coltan), cassiterite, gold, wolframite, and their derivatives, tantalum, tin and tungsten, that are necessary for the functionality or production of the products.
A copy of Entellus’s Conflict Minerals Report for the year ended December 31, 2016 is filed as Exhibit 1.01 to this specialized
disclosure report on Form SD and is publicly available under the “Investors—Corporate Governance” section of Entellus’s corporate website at www.entellusmedical.com.
Item 1.02 Exhibit
A copy of
Entellus’s Conflict Minerals Report for the year ended December 31, 2016 is filed as Exhibit 1.01 to this specialized disclosure report on Form SD and is publicly available under the “Investors—Corporate Governance” section
of Entellus’s corporate website at www.Entellus.com.
Item 2.01 Exhibits
The following exhibit is being filed with this specialized disclosure report on Form SD:
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Exhibit No.
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Description
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1.01
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Conflict Minerals Report for the year ended December 31, 2016, as required by Items 1.01 and 1.02 of this Specialized Disclosure Report on Form SD
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SIGNATURES
Pursuant to the requirements of the Securities Exchange Act of 1934, as amended, the registrant has duly caused this report to be signed on
its behalf by the duly authorized undersigned.
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ENTELLUS MEDICAL, INC.
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Dated: May 31, 2017
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By:
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/s/ Jonelle R. Burnham
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Name:
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Jonelle R. Burnham
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Title:
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Vice President, General Counsel and
Compliance
Officer
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ENTELLUS MEDICAL, INC.
FORM SD
SPECIALIZED
DISCLOSURE REPORT
EXHIBIT INDEX
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Exhibit
No.
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Description
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Method of
Filing
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1.01
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Conflict Minerals Report for the year ended December 31, 2016, as required by Items 1.01 and 1.02 of this Specialized Disclosure Report on Form SD
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Filed herewith
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