Initial Statement of Beneficial Ownership (3)
16 Março 2023 - 1:57PM
Edgar (US Regulatory)
FORM 3
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES
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OMB APPROVAL
OMB Number:
3235-0104
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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
*
Cook Jason |
2. Date of Event Requiring Statement (MM/DD/YYYY)
3/7/2023
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3. Issuer Name and Ticker or Trading Symbol
Bluejay Diagnostics, Inc. [BJDX]
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(Last)
(First)
(Middle)
C/O BLUEJAY DIAGNOSTICS, INC., 360 MASSACHUSETTS AVE, SUITE 203 |
4. Relationship of Reporting Person(s) to Issuer (Check all applicable)
_____ Director _____ 10% Owner
___X___ Officer (give title below) _____ Other (specify below)
Chief Technology Officer / |
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(Street)
ACTON, MA 01720
(City)
(State)
(Zip)
| 5. If Amendment, Date Original Filed(MM/DD/YYYY)
| 6. Individual or Joint/Group Filing(Check Applicable Line)
_X_ Form filed by One Reporting Person
___ Form filed by More than One Reporting Person
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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) |
| Common Stock | 5000 | D | |
| Common Stock | 44900 | D | |
Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities)
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1. Title of Derivate Security
(Instr. 4) | 2. Date Exercisable and Expiration Date
(MM/DD/YYYY) | 3. Title and Amount of Securities Underlying Derivative Security
(Instr. 4) | 4. Conversion or Exercise Price of Derivative Security | 5. Ownership Form of Derivative Security: 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 |
| Options to purchase common stock | (1) | 7/7/2031 | Common Stock | 75000 | $3.50 | D | |
| Options to purchase common stock | (2) | 2/25/2032 | Common Stock | 5324 | $1.09 | D | |
| Explanation of Responses: |
| (1) | The stock options vest as follows: a) 41,668 immediately upon grant, and b) 8,333 each upon attainment of four different performance conditions |
| (2) | The stock options vest in three equal installments on the first, second and third anniversaries of the grant date. |
Reporting Owners
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| Reporting Owner Name / Address | Relationships |
| Director | 10% Owner | Officer | Other |
Cook Jason
C/O BLUEJAY DIAGNOSTICS, INC.
360 MASSACHUSETTS AVE, SUITE 203
ACTON, MA 01720 |
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| Chief Technology Officer |
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Signatures
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| /s/ Jason Cook | | 3/16/2023 |
| **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 control number. |
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