UNITED STATES
SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
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SCHEDULE 13D
Under the Securities Exchange Act of 1934
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MICROBOT MEDICAL INC.
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(Name of Issuer)
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Common Stock, par value $0.01 per Share
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(Title of Class of Securities)
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59503A 105
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(CUSIP Number)
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Moshe Shoham
22 Bedolach Street
Hoshaya M.P. Hamovil 17915, Israel
972 4 6569788
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(Name, Address and Telephone Number of Person Authorized to
Receive Notices and Communications)
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November 28, 2016
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(Date of Event which Requires Filing of this Statement)
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If the filing person has previously filed a statement on Schedule 13G to report the acquisition that is the subject of this Schedule 13D, and is filing this schedule because of §§240.13d-1(e), 240.13d-1(f) or 240.13d-1(g), check the following box. o
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NOTE: Schedules filed in paper format shall include a signed original and five copies of the schedule, including all exhibits. See Rule 13d-7 for other parties to whom copies are to be sent.
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*The remainder of this cover page shall be filled out for a reporting person's initial filing on this form with respect to the subject class of securities, and for any subsequent amendment containing information which would alter disclosures provided in a prior cover page.
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CUSIP No.
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59503A 105
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1.
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Names of Reporting Person:
Moshe Shoham
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2.
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Check the Appropriate Box if a Member of a Group (See Instructions)
(a) o
(b) o
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3.
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SEC Use Only
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4.
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Source of Funds (See Instructions):
SC
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5.
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Check if Disclosure of Legal Proceedings Is Required Pursuant to Items 2(d) or 2(e)
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o
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6.
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Citizenship or Place of Organization:
Israel
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NUMBER OF
SHARES
BENEFICIALLY
OWNED BY
EACH
REPORTING
PERSON WITH
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7.
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Sole Voting Power:
2,550,231 (see Item 5)
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8.
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Shared Voting Power:
None
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9.
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Sole Dispositive Power:
2,550,231 (see Item 5)
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10.
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Shared Dispositive Power:
None
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11.
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Aggregate Amount Beneficially Owned by Each Reporting Person:
2,550,231
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12.
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Check if the Aggregate Amount in Row (11) Excludes Certain Shares (See Instructions):
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o
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13.
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Percent of Class Represented by Amount in Row (11):
6.9%
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14.
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Type of Reporting Person (See Instructions):
IN
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(a)
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As of the date of this report, Dr. Shoham beneficially owns 2,550,231 shares of Company Common Stock, which number of shares represents approximately 6.9% of the outstanding Common Stock based on 36,254,240 shares of outstanding Company Common Stock. Includes options granted to Dr. Shoham to purchase an aggregate of 708,141 shares of Company Common Stock, which options are currently exercisable.
The percentage of ownership reported in this Item 5 was calculated in accordance with Rule 13d-3(d)(1)(i) promulgated under the Securities Exchange Act of 1934, as amended.
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(b)
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Dr. Shoham has power to vote or direct the vote, and to dispose or direct the disposition, of 1,842,090 shares of Company Common Stock, and 708,141 shares underlying options.
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(c)
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Except as described herein, the Reporting Person has not effected any transaction in Company Common Stock in the past 60 days.
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(d) and (e)
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Not applicable
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Exhibit 1: Agreement and Plan of Merger and Reorganization (1)
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(1)
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Incorporated by reference to the Company’s Proxy Statement on Schedule 14A filed with the SEC on September 27, 2016.
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By:
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/s/ Moshe Shoham
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Name:
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Moshe Shoham
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