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