SEC FORM
3
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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| OMB APPROVAL |
| OMB Number: |
3235-0104 |
| Estimated average burden |
| hours per response: |
0.5 |
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1. Name and Address of Reporting Person*
| 780 DEDHAM STREET, SUITE 800 |
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(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year)
05/06/2015
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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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Director |
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10% Owner |
| X |
Officer (give title below) |
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Other (specify below) |
| see remarks |
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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)
| X |
Form filed by One Reporting Person |
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Form filed by More than One Reporting Person |
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| Table I - Non-Derivative Securities Beneficially Owned |
|---|
| 1. Title of Security (Instr.
4)
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2.
Amount of Securities Beneficially Owned (Instr.
4)
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3. Ownership Form: Direct (D) or Indirect (I) (Instr.
5)
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4. Nature of Indirect Beneficial Ownership (Instr.
5)
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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)
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2. Date Exercisable and Expiration Date
(Month/Day/Year) |
3. Title and Amount of Securities Underlying Derivative Security (Instr.
4)
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4. Conversion or Exercise Price of Derivative Security
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5. Ownership Form: Direct (D) or Indirect (I) (Instr.
5)
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6. Nature of Indirect Beneficial Ownership (Instr.
5)
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| Date Exercisable |
Expiration Date |
Title |
Amount or Number of Shares |
| Stock Option (right to purchase) |
|
06/13/2022 |
Common Stock |
36,231 |
0.48 |
D |
|
| Stock Option (right to purchase) |
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01/30/2023 |
Common Stock |
1,811 |
0.48 |
D |
|
| Stock Option (right to purchase) |
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03/05/2024 |
Common Stock |
19,299 |
0.28 |
D |
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| Stock Option (right to purchase) |
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03/19/2025 |
Common Stock |
23,429 |
5.73 |
D |
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| Explanation of Responses: |
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| Remarks: |
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/s/ Paul Brannelly as Attorney-In-Fact For Ernest A. Kopecky |
05/06/2015 |
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** 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. |
POWER OF ATTORNEY
Know all by these presents, that the undersigned hereby constitutes
and appoints each of Paul Brannelly and Michael T. Heffernan, with full power
to act singly, as the undersigned's true and lawful attorney-in-fact with full
power of substitution to:
(1) execute for and on behalf of the undersigned, in the
undersigned's capacity as an officer and/or director and/or beneficial owner
of Collegium Pharmaceutical Inc. (the "Company"), Form ID Application,
Forms 3, 4 and 5 in accordance with Section 16(a) of the Securities Exchange Act
of 1934, as amended and the rules thereunder;
(2) do and perform any and all acts for and on behalf of the
undersigned which may be necessary or desirable to complete and execute
any such Form ID Application, Forms 3, 4 or 5, complete and execute any
amendment or amendments thereto and timely file such forms with the
United States Securities and Exchange Commission and any stock exchange
or similar authority; and
(3) take any other action of any type whatsoever in connection
with the foregoing which, in the opinion of such attorney-in-fact, may be of
benefit to, in the best interest of, or legally required by, the undersigned,
it being understood that the documents executed by such attorney-in-fact
on behalf of the undersigned pursuant to this Power of Attorney shall be in
such form and shall contain such terms and conditions as such attorney-in-fact
may approve in such attorney-in-fact's discretion.
The undersigned hereby grants to the attorney-in-fact full power and
authority to do and perform any and every act and thing whatsoever requisite,
necessary or proper to be done in the exercise of any of the rights and powers
herein granted, as fully to all intents and purposes as the undersigned might
or could do if personally present, with full power of substitution or revocation,
hereby ratifying and confirming all that such attorney-in-fact, or such
attorney-in-fact's substitute or substitutes, shall lawfully do or cause to be
done by virtue of this power of attorney and the rights and powers herein
granted.
This power of attorney shall remain in full force and effect until
revoked by the undersigned in a signed writing delivered to the attorney-in-fact.
IN WITNESS WHEREOF, the undersigned has caused this Power of Attorney
to be executed as of the 24th day of April, 2015.
/s/Ernest A. Kopecky, Ph.D.
Name: Ernest A. Kopecky, Ph.D.
Title: VP, Clinical Development and
Head of Neuroscience
Development
