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*
| 4350 LA JOLLA VILLAGE DRIVE, SUITE 950 |
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(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year)
06/14/2010
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3. Issuer Name and Ticker or Trading Symbol
MEDICINOVA INC
[ MNOV ]
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
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Director |
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10% Owner |
| X |
Officer (give title below) |
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Other (specify below) |
| Chief Business Officer |
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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: |
| Remarks: |
|
| No securities are beneficially owned. |
|
/s/ Michael Coffee |
06/15/2010 |
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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. |
rrd250006_282107.html
Power of Attorney
I, Michael Denis Coffee, of 4350 La Jolla Village Drive, Suite 950, San Diego
CA, 92122 hereby appoint Shintaro Asako, as my recognized representative and
true and lawful attorney-in-fact to make, execute, sign, acknowledge and file
with the Securities and Exchange Commission (the "SEC") as necessary any
documents relating to my service as an executive officer of MediciNova, Inc. and
any amendments to such documents.
This is the only power granted by this Power of Attorney. This Power of Attorney
applies to all future documents filed with the SEC relating to my service as an
executive officer of MediciNova, Inc. and any amendments thereto. This Power of
Attorney is revocable by me at any time. Third parties receiving a duly executed
copy, a copy uploaded in text or html format or facsimile of this Power of
Attorney may rely upon this Power of Attorney.
Signature: /s/ Michael Coffee
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Name: Michael Coffee
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Title: Chief Business Officer of MediciNova, Inc.
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Date: June 14, 2010
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