Initial Statement of Beneficial Ownership (3)
June 22 2021 - 6:00PM
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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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
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Gurrola Sandra M |
2. Date of Event Requiring Statement (MM/DD/YYYY)
6/21/2021
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3. Issuer Name and Ticker or Trading Symbol
Brooklyn ImmunoTherapeutics, Inc. [BTX]
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(Last)
(First)
(Middle)
C/O BROOKLYN IMMUNOTHERAPEUTICS, INC., 140 58TH STREET, BUILDING A, SUITE 2100 |
4. Relationship of Reporting Person(s) to Issuer (Check all applicable)
_____ Director _____ 10% Owner ___X___ Officer (give title below) _____ Other (specify below) Vice President of Finance / |
(Street)
BROOKLYN, NY 11220
(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 | 8203 | 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 |
Explanation of Responses: |
Remarks: Ms. Gurrola previously served as Senior Vice President of Finance for Brooklyn ImmunoTherapeutics, Inc. (formerly NTN Buzztime, Inc.) (the "Company"). As reported on an exit Form 4 filed with the Securities and Exchange Commission on March 26, 2021, Ms. Gurrola ceased to be a Section 16 Reporting Officer of the Company effective as of March 25, 2021. Effective as of June 21, 2021, Ms. Gurrola was appointed Vice President of Finance of the Company and thereby again became a Section 16 Reporting Officer of the Company. This Form 3 presents a current listing of all holdings of Company securities as of the effective time of Ms. Gurrola's appointment as Vice President of Finance of the Company.
Exhibit List: Exhibit 24 - Power of Attorney |
Reporting Owners
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Reporting Owner Name / Address | Relationships |
Director | 10% Owner | Officer | Other |
Gurrola Sandra M C/O BROOKLYN IMMUNOTHERAPEUTICS, INC. 140 58TH STREET, BUILDING A, SUITE 2100 BROOKLYN, NY 11220 |
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| Vice President of Finance |
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Signatures
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/s/ Mark L. Johnson, Attorney-in-Fact for Sandra M. Gurrola | | 6/22/2021 |
**Signature of Reporting Person | Date |
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