0000905718-21-001096.txt : 20210817
0000905718-21-001096.hdr.sgml : 20210817
20210817123947
ACCESSION NUMBER: 0000905718-21-001096
CONFORMED SUBMISSION TYPE: 4
PUBLIC DOCUMENT COUNT: 1
CONFORMED PERIOD OF REPORT: 20210817
FILED AS OF DATE: 20210817
DATE AS OF CHANGE: 20210817
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: Nardo Christopher J.
CENTRAL INDEX KEY: 0001870247
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-40739
FILM NUMBER: 211182011
MAIL ADDRESS:
STREET 1: C/O DERMATA THERAPEUTICS, INC.
STREET 2: 3525 DEL MAR HEIGHTS RD., #332
CITY: SAN DIEGO
STATE: CA
ZIP: 92130
ISSUER:
COMPANY DATA:
COMPANY CONFORMED NAME: Dermata Therapeutics, Inc.
CENTRAL INDEX KEY: 0001853816
STANDARD INDUSTRIAL CLASSIFICATION: PHARMACEUTICAL PREPARATIONS [2834]
IRS NUMBER: 000000000
STATE OF INCORPORATION: DE
FISCAL YEAR END: 1231
BUSINESS ADDRESS:
STREET 1: 3525 DEL MAR HEIGHTS RD., #332
CITY: SAN DIEGO
STATE: CA
ZIP: 92130
BUSINESS PHONE: (858)-223-0882
MAIL ADDRESS:
STREET 1: 3525 DEL MAR HEIGHTS RD., #332
CITY: SAN DIEGO
STATE: CA
ZIP: 92130
4
1
dermata_fm4aug172021.xml
X0306
4
2021-08-17
0
0001853816
Dermata Therapeutics, Inc.
DRMA
0001870247
Nardo Christopher J.
3525 DEL MAR HEIGHTS RD., #332
SAN DIEGO
CA
92130
0
1
0
0
Senior VP, Development
Common Stock
2021-08-17
4
C
0
2439
A
2439
I
By Nardo Family Trust Dated October 3, 2001
Common Stock
25121
D
Series 1 Preferred Stock
2021-08-17
4
C
0
50000
0
D
Common Stock
2439
0
I
By Nardo Family Trust Dated October 3, 2001
The Series 1 Preferred Stock converted into Common Stock of the Issuer upon consummation of the Issuer's initial public offering (the "IPO"). The Series 1 Preferred Stock was convertible at any time and had no expiration date.
Reporting Person disclaims beneficial ownership of these securities except to the extent of their pecuniary interest therein, and the inclusion of these shares in this report shall not be deemed an admission of beneficial ownership of all of the reported shares for purposes of Section 16 or for any other purpose.
/s/ Gerald T. Proehl, Attorney-in-Fact
2021-08-17