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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1. Name and Address of Reporting Person*
Mahmood Tahir Ph.D.

(Last) (First) (Middle)
C/O APPLIED MOLECULAR TRANSPORT INC.
1 TOWER PLACE, SUITE 850

(Street)
SOUTH SAN FRANCISCO CA 94080

(City) (State) (Zip)
2. Date of Event Requiring Statement (Month/Day/Year)
06/04/2020
3. Issuer Name and Ticker or Trading Symbol
Applied Molecular Transport Inc. [ AMTI ]
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
X Director 10% Owner
X Officer (give title below) Other (specify below)
Chief Executive Officer
5. If Amendment, Date of Original Filed (Month/Day/Year)
6. Individual or Joint/Group Filing (Check Applicable Line)
X Form filed by One Reporting Person
Form filed by More than One Reporting Person
Table I - Non-Derivative Securities Beneficially Owned
1. Title of Security (Instr. 4) 2. Amount of Securities Beneficially Owned (Instr. 4) 3. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) 4. Nature of Indirect Beneficial Ownership (Instr. 5)
Common Stock 176,657 I By Irrevocable Trust(1)
Common Stock 345,000 I By GRAT(2)
Common Stock 3,078,343 I By Living Trust(3)
Table II - Derivative Securities Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
1. Title of Derivative Security (Instr. 4) 2. Date Exercisable and Expiration Date (Month/Day/Year) 3. Title and Amount of Securities Underlying Derivative Security (Instr. 4) 4. Conversion or Exercise Price of Derivative Security 5. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) 6. Nature of Indirect Beneficial Ownership (Instr. 5)
Date Exercisable Expiration Date Title Amount or Number of Shares
Explanation of Responses:
1. These shares are held directly by The Mahmood 2017 Irrevocable Trust Agreement for which Dr. Mahmood serves as trustee and over which shares Dr. Mahmood holds voting and dispositive power.
2. These shares are held directly by the Tahir Mahmood 2019 Annuity Trust for which Dr. Mahmood serves as trustee and over which shares Dr. Mahmood holds voting and dispositive power.
3. These shares are held directly by the Mahmood-Shamsi Living Trust Agreement for which Dr. Mahmood and his spouse serve as co-trustees and over which shares Dr. Mahmood and his spouse hold voting and dispositive power.
Remarks:
Date set forth above represents the effective date of issuer's initial public offering.
/s/Brandon Hants Attorney-in-Fact for Tahir Mahmood 06/04/2020
** 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.