0001144204-12-000815.txt : 20120105 0001144204-12-000815.hdr.sgml : 20120105 20120105174621 ACCESSION NUMBER: 0001144204-12-000815 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20111018 FILED AS OF DATE: 20120105 DATE AS OF CHANGE: 20120105 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: PAPPAJOHN JOHN CENTRAL INDEX KEY: 0000897464 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 000-26285 FILM NUMBER: 12512348 MAIL ADDRESS: STREET 1: 1660 WALT WHITMAN ROAD STREET 2: SUITE 105 CITY: MELVILLE STATE: NY ZIP: 11747 4 1 v244789_form4.xml OWNERSHIP DOCUMENT X0304 4 2011-10-18 0 0000822370 CNS RESPONSE, INC. CNSO 0000897464 PAPPAJOHN JOHN C/O CNS RESPONSE, INC. 85 ENTERPRISE, SUITE 410 ALISO VIEJO CA 92656 1 0 1 0 Subordinated Convertible Note 0.10 2011-10-18 4 A 0 250000 A 2011-10-18 2012-10-18 Common Stock 2500000 250000 D Common Stock Warrant 0.10 2011-10-18 4 A 0 1250000 A 2011-10-18 2016-11-17 Common Stock 1250000 1250000 D Common Stock Warrant 0.10 2011-11-11 4 A 0 1250000 A 2011-10-18 2016-11-17 Common Stock 1250000 2500000 D Subordinated Convertible Note 0.10 2011-11-11 4 A 0 250000 A 2011-11-11 2012-11-11 Common Stock 2500000 500000 D Common Stock Warrant 0.10 2011-11-11 4 A 0 2500000 A 2011-11-11 2016-11-10 Common Stock 2500000 5000000 D Subordinated Convertible Note 0.10 2011-12-27 4 A 0 250000 A 2011-12-27 2012-12-27 Common Stock 2500000 750000 D Common Stock Warrant 0.10 2011-12-27 4 A 0 2500000 A 2011-12-27 2016-12-26 Common Stock 2500000 7500000 D Note and related warrant were issued for $250,000 in cash. On November 11, 2011, the 10/18/11 Note and Warrant Purchase Agreement was amended and restated to increase the warrant coverage from 50% to 100%, resulting in the issuance of additional warrants to Mr. Pappajohn. Note and related warrant were issued for $250,000 in cash. Note and related warrant were issued for $250,000 in cash. /s/ John Pappajohn 2012-01-05