0001213900-22-002005.txt : 20220113 0001213900-22-002005.hdr.sgml : 20220113 20220113193013 ACCESSION NUMBER: 0001213900-22-002005 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20220110 FILED AS OF DATE: 20220113 DATE AS OF CHANGE: 20220113 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: CHASE DONALD R CENTRAL INDEX KEY: 0001247473 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-41031 FILM NUMBER: 22530161 MAIL ADDRESS: STREET 1: 39 TIMBER RIDGE RD. CITY: WEST SPRINGFIELD STATE: MA ZIP: 01089 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: Bluejay Diagnostics, Inc. CENTRAL INDEX KEY: 0001704287 STANDARD INDUSTRIAL CLASSIFICATION: SURGICAL & MEDICAL INSTRUMENTS & APPARATUS [3841] IRS NUMBER: 473552922 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 360 MASSACHUSETTS AVENUE, SUITE 203 CITY: ACTON STATE: MA ZIP: 01720 BUSINESS PHONE: (978) 631-0152 MAIL ADDRESS: STREET 1: 360 MASSACHUSETTS AVENUE, SUITE 203 CITY: ACTON STATE: MA ZIP: 01720 4 1 ownership.xml X0306 4 2022-01-10 0 0001704287 Bluejay Diagnostics, Inc. BJDX 0001247473 CHASE DONALD R C/O BLUEJAY DIAGNOSTICS, INC 360 MASSACHUSETTS AVENUE, SUITE 203 ACTON MA 01720 1 0 0 0 Option to purchase common stock 2.79 2022-01-10 4 A 0 25000 A 2032-01-10 Common Stock 25000 110762 D The stock options set forth in this table vest on December 15, 2022, subject to the grantee's continued service to the Company on the vesting date. The stock options were issued in connection with the reporting person's Board of Director services to the Company. /s/ Donald Chase 2022-01-13