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)
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2. Date of Event Requiring Statement
(Month/Day/Year) 05/06/2015 |
3. Issuer Name and Ticker or Trading Symbol
COLLEGIUM PHARMACEUTICAL, INC [ COLL ] |
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
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5. If Amendment, Date of Original Filed
(Month/Day/Year) |
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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 A Convertible Preferred Stock | (1) | (1) | Common Stock | 582,490(1) | (1) | I(2)(3) | By: Frazier Healthcare VI, L.P.(4) |
Series B Convertible Preferred Stock | (1) | (1) | Common Stock | 222,231(1) | (1) | I(2)(3) | By: Frazier Healthcare VI, L.P.(4) |
Series C Convertible Preferred Stock | (1) | (1) | Common Stock | 392,113(1) | (1) | I(2)(3) | By: Frazier Healthcare VI, L.P.(4) |
Series D Convertible Preferred Stock | (1) | (1) | Common Stock | 532,764(1) | (1) | I(2)(3) | By: Frazier Healthcare VI, L.P.(4) |
1. Name and Address of Reporting Person*
(Street)
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1. Name and Address of Reporting Person*
(Street)
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1. Name and Address of Reporting Person*
(Street)
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1. Name and Address of Reporting Person*
(Street)
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1. Name and Address of Reporting Person*
(Street)
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1. Name and Address of Reporting Person*
(Street)
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1. Name and Address of Reporting Person*
(Street)
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Explanation of Responses: |
1. All series of Convertible Preferred Stock will automatically convert into Collegium Pharmaceutical, Inc. (the "Issuer") 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. This report is filed jointly by Frazier Healthcare VI, L.P. ("FHVI"), FHM VI, L.P. ("FHM LP"), FHM VI, L.L.C. ("FHM LLC"), Nathan Every ("Every"), Alan Frazier ("Frazier"), Nader Naini ("Naini") and James Topper ("Topper"), all of whom share beneficial ownership of more than 10% of the capital stock of the Issuer. FHVI is the record holder of 4,019,183 shares of Series A Convertible Preferred Stock, which will automatically convert into 582,490 shares of common stock upon the closing of the Issuer's initial public offering. FHVI is the record holder of 1,533,399 shares of Series B Convertible Preferred Stock, which will automatically convert into 222,231 shares of common stock upon the closing of the Issuer's initial public offering. (continued in footnote 3) |
3. FHVI is the record holder of 1,533,399 shares of Series B Convertible Preferred Stock, which will automatically convert into 222,231 shares of common stock upon the closing of the Issuer's initial public offering. FHVI is the record holder of 2,705,585 shares of Series C Convertible Preferred Stock, which will automatically convert into 392,113 shares of common stock upon the closing of the Issuer's initial public offering. FHVI is the record holder of 3,676,078 shares of Series D Convertible Preferred Stock, which will automatically convert into 532,764 shares of common stock upon the closing of the Issuer's initial public offering. |
4. The shares are held by FHVI. The general partner of FHVI is FHM LP, a limited partnership, the general partner of which is FHM LLC. The members of FHM LLC are Every, Frazier, Naini, Heron, and Topper. These individuals share voting and investment power over the shares held by FHVI. Each of these individuals disclaims beneficial ownership of such shares, except to the extent of his pecuniary interest. |
Remarks: |
Frazier Healthcare VI, L.P., By: FHM VI, L.P., its general partner, By FHM VI, L.L.C., its general partner, By: /s/ Steve Bailey, Chief Financial Officer | 05/06/2015 | |
FHM VI, L.P., By: FHM VI, L.L.C., its general partner, By: /s/ Steve Bailey, Chief Financial Officer | 05/06/2015 | |
FHM VI, L.L.C., By: /s/ Steve Bailey, Chief Financial Officer | 05/06/2015 | |
/s/ Alan Frazier | 05/06/2015 | |
/s/ Nader Naini | 05/06/2015 | |
/s/ James Topper | 05/06/2015 | |
/s/ Nathan Every | 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. |