SEC Form 3
FORM 3 | UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934 or Section 30(h) of the Investment Company Act of 1940 |
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1. Name and Address of Reporting Person*
(Street)
| 2. Date of Event Requiring Statement (Month/Day/Year) 05/06/2015 | 3. Issuer Name and Ticker or Trading Symbol COLLEGIUM PHARMACEUTICAL, INC [ COLL ] | |||||||||||||
4. Relationship of Reporting Person(s) to Issuer (Check all applicable)
| 5. If Amendment, Date of Original Filed (Month/Day/Year) | ||||||||||||||
6. Individual or Joint/Group Filing (Check Applicable Line)
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Table I - Non-Derivative Securities Beneficially Owned | |||
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1. Title of Security (Instr. 4) | 2. Amount of Securities Beneficially Owned (Instr. 4) | 3. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) | 4. Nature of Indirect Beneficial Ownership (Instr. 5) |
Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) | |||||||
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1. Title of Derivative Security (Instr. 4) | 2. Date Exercisable and Expiration Date (Month/Day/Year) | 3. Title and Amount of Securities Underlying Derivative Security (Instr. 4) | 4. Conversion or Exercise Price of Derivative Security | 5. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) | 6. Nature of Indirect Beneficial Ownership (Instr. 5) | ||
Date Exercisable | Expiration Date | Title | Amount or Number of Shares | ||||
Series B Convertible Preferred Stock | (1) | (1) | Common Stock | 1,860,570(1) | (1) | I | By: Longitude Venture Partners, L.P.(2) |
Series B Convertible Preferred Stock | (1) | (1) | Common Stock | 37,290(1) | (1) | I | By: Longitude Capital Associates, L.P.(2) |
Series C Convertible Preferred Stock | (1) | (1) | Common Stock | 458,102(1) | (1) | I | By: Longitude Venture Partners, L.P.(2) |
Series C Convertible Preferred Stock | (1) | (1) | Common Stock | 9,182(1) | (1) | I | By: Longitude Capital Associates, L.P.(2) |
Series D Convertible Preferred Stock | (1) | (1) | Common Stock | 731,214(1) | (1) | I | By: Longitude Venture Partners, L.P.(2) |
Series D Convertible Preferred Stock | (1) | (1) | Common Stock | 14,656(1) | (1) | I | By: Longitude Capital Associates, L.P.(2) |
Explanation of Responses: |
1. All series of Convertible Preferred Stock will automatically convert into Collegium Pharmaceutical, Inc. common stock on a 1-for-6.9 basis immediately prior to the closing of the initial public offering and have no expiration date. |
2. The shares are held by Longitude Venture Partners, L.P. and Longitude Capital Associates, L.P. (collectively, the "Longitude Funds"). Longitude Capital Partners, LLC is the general partner of the Longitude Funds and may be deemed to have sole voting investment and dispositive power over the shares held by the Longitude Funds. Patrick G. Enright and Juliet Tammenoms Bakker are managing members of Longitude Capital Partners, LLC and in their capacity as such, may be deemed to exercise shared voting and investment power over the shares held by the reporting persons. David Hirsch is a member of Longitude Capital Partners, LLC. Dr. Hirsch disclaims beneficial ownership of such shares except to the extent of his pecuniary interest therein. |
Remarks: |
/s/ Paul Brannelly as Attorney-In-Fact For David Hirsch | 05/06/2015 | |
** Signature of Reporting Person | Date | |
Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | ||
* If the form is filed by more than one reporting person, see Instruction 5 (b)(v). | ||
** Intentional misstatements or omissions of facts constitute Federal Criminal Violations See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). | ||
Note: File three copies of this Form, one of which must be manually signed. If space is insufficient, see Instruction 6 for procedure. | ||
Persons who respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB Number. |