Statement of Changes in Beneficial Ownership (4)
November 07 2019 - 4:16PM
Edgar (US Regulatory)
FORM 4
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Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b).
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES
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OMB APPROVAL
OMB Number:
3235-0287
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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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Nissensohn Carlos Jaime |
2. Issuer Name and Ticker or Trading Symbol
Quest Solution, Inc.
[
QUES
]
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
_____ Director __X__ 10% Owner _____ Officer (give title below) _____ Other (specify below)
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(Last)
(First)
(Middle)
C/O QUEST SOLUTION, INC., 1865 WEST 2100 SOUTH |
3. Date of Earliest Transaction
(MM/DD/YYYY)
11/5/2019
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(Street)
SALT LAKE CITY, UT 84119
(City)
(State)
(Zip)
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4. 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
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Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
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1.Title of Security (Instr. 3)
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2. Trans. Date
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2A. Deemed Execution Date, if any
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3. Trans. Code (Instr. 8)
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4. Securities Acquired (A) or Disposed of (D) (Instr. 3, 4 and 5)
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5. Amount of Securities Beneficially Owned Following Reported Transaction(s) (Instr. 3 and 4)
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6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4)
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7. Nature of Indirect Beneficial Ownership (Instr. 4)
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Code
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V
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Amount
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(A) or (D)
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Price
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Common Stock
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11/5/2019
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A
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317796
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A
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$0 (1)
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14586111
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I
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See Footnote (2)
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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 Derivate Security (Instr. 3)
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2. Conversion or Exercise Price of Derivative Security
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3. Trans. Date
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3A. Deemed Execution Date, if any
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4. Trans. Code (Instr. 8)
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5. Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr. 3, 4 and 5)
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6. Date Exercisable and Expiration Date
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7. Title and Amount of Securities Underlying Derivative Security (Instr. 3 and 4)
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8. Price of Derivative Security (Instr. 5)
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9. Number of derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4)
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10. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 4)
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11. Nature of Indirect Beneficial Ownership (Instr. 4)
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Code
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V
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(A)
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(D)
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Date Exercisable
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Expiration Date
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Title
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Amount or Number of Shares
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Explanation of Responses:
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(1)
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On October 5, 2018, Quest Solution, Inc. (the "Company") entered into a purchase agreement (the "Purchase Agreement") with Campbeltown Consulting, Ltd. ("Campbeltown"), Pursuant to the Purchase Agreement, the Company issued to Campbeltown a convertible promissory note with a principal amount of $700,000 and an interest rate of six percent (6%) per annum (the "Note"). Pursuant to the Note, Campbeltown may convert any and all accrued and unpaid principal and interest into shares of the Company's common stock at an exercise price of $0.236 per share (the "Exercise Price"). As of November 4, 2019, the accrued and unpaid balance under the Note was $150,000 (the "Balance"). On November 5, 2019, the Company and Campbeltown entered into a conversion agreement, pursuant to which Campbeltown agreed to convert $75,000 of the Balance at the Exercise Price and into 317,796 shares of the Company's common stock.
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(2)
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The shares are held by Campbeltown Consulting Ltd., which is beneficially owned by Mr. Nissensohn.
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Reporting Owners
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Reporting Owner Name / Address
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Relationships
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Director
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10% Owner
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Officer
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Other
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Nissensohn Carlos Jaime C/O QUEST SOLUTION, INC. 1865 WEST 2100 SOUTH SALT LAKE CITY, UT 84119
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X
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Signatures
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/s/ Carlos Jaime Nissensohn
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11/7/2019
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**Signature of Reporting Person
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Date
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
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*
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If the form is filed by more than one reporting person, see Instruction 4(b)(v).
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**
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Intentional misstatements or omissions of facts constitute Federal Criminal Violations. See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a).
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Note:
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File three copies of this Form, one of which must be manually signed. If space is insufficient, see Instruction 6 for procedure.
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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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