0001615774-15-002381.txt : 20150824
0001615774-15-002381.hdr.sgml : 20150824
20150824184508
ACCESSION NUMBER: 0001615774-15-002381
CONFORMED SUBMISSION TYPE: 4
PUBLIC DOCUMENT COUNT: 1
CONFORMED PERIOD OF REPORT: 20150820
FILED AS OF DATE: 20150824
DATE AS OF CHANGE: 20150824
ISSUER:
COMPANY DATA:
COMPANY CONFORMED NAME: CNS RESPONSE, INC.
CENTRAL INDEX KEY: 0000822370
STANDARD INDUSTRIAL CLASSIFICATION: SERVICES-MISC HEALTH & ALLIED SERVICES, NEC [8090]
IRS NUMBER: 870419387
STATE OF INCORPORATION: DE
FISCAL YEAR END: 0930
BUSINESS ADDRESS:
STREET 1: 85 ENTERPRISE
STREET 2: SUITE 410,
CITY: ALISO VIEJO
STATE: CA
ZIP: 92656
BUSINESS PHONE: (714) 545 3288
MAIL ADDRESS:
STREET 1: 85 ENTERPRISE
STREET 2: SUITE 410,
CITY: ALISO VIEJO
STATE: CA
ZIP: 92656
FORMER COMPANY:
FORMER CONFORMED NAME: STRATIVATION, INC.
DATE OF NAME CHANGE: 20051115
FORMER COMPANY:
FORMER CONFORMED NAME: SalesTactix, Inc.
DATE OF NAME CHANGE: 20040805
FORMER COMPANY:
FORMER CONFORMED NAME: AGE RESEARCH INC
DATE OF NAME CHANGE: 19990210
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: Smith Robin L
CENTRAL INDEX KEY: 0001365035
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-35527
FILM NUMBER: 151071901
MAIL ADDRESS:
STREET 1: C/O PHASE III MEDICAL, INC.
STREET 2: 330 SOUTH SERVICE ROAD, SUITE 120
CITY: MELVILLE
STATE: NY
ZIP: 11747
4
1
s101744_form4.xml
4
X0306
4
2015-08-20
0
0000822370
CNS RESPONSE, INC.
CNSO
0001365035
Smith Robin L
C/O CNS RESPONSE, INC.,85 ENTERPRISE
SUITE 410
ALISO VIEJO
CA
92656
1
0
0
0
Common Stock
2015-08-20
4
A
0
750000
0
A
750000
D
Option to Purchase
0.055
2015-08-20
4
A
0
250000
0
A
2025-08-19
Common Stock
250000
250000
D
Represents a grant of shares of restricted stock vesting pro rata over 36 months begining on August 20, 2015.
These options vest pro rata over 36 months beginning on August 20, 2015.
/s/ Robin L. Smith
2015-08-24