Initial Statement of Beneficial Ownership (3)
January 05 2021 - 04:37PM
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
Estimated average burden
hours per response... 0.5 |
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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 * Akhavan Ramin |
2. Date of Event Requiring Statement
(MM/DD/YYYY)
1/5/2021
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3. Issuer Name and Ticker or Trading
Symbol DermTech, Inc. [DMTK] |
(Last)
(First)
(Middle)
C/O DERMTECH, INC., 11099 N. TORREY PINES RD. SUITE
100 |
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)_____
Director _____
10% Owner
___X___ Officer (give title
below) _____
Other (specify below)
General Counsel / |
(Street)
LA
JOLLA, CA 92037
(City)
(State)
(Zip)
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5. If Amendment, Date Original
Filed(MM/DD/YYYY)
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6. Individual or Joint/Group
Filing(Check Applicable
Line)_X_ Form filed by One Reporting
Person
___ Form filed by More than One Reporting Person |
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 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 |
Explanation of
Responses: |
Remarks:
Exhibit List Exhibit 24 - Power of Attorney of Ramin Akhavan
No securities are beneficially owned. |
No securities are beneficially
owned. |
Reporting
Owners
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Reporting Owner Name / Address |
Relationships
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Director |
10% Owner |
Officer |
Other |
Akhavan Ramin
C/O DERMTECH, INC.
11099 N. TORREY PINES RD. SUITE 100
LA JOLLA, CA 92037 |
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General Counsel |
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Signatures
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/s/ Jason S. Miller,
attorney-in-fact |
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1/5/2021 |
**Signature of Reporting
Person |
Date |