0000905148-16-001919.txt : 20161004
0000905148-16-001919.hdr.sgml : 20161004
20161004173842
ACCESSION NUMBER: 0000905148-16-001919
CONFORMED SUBMISSION TYPE: 4
PUBLIC DOCUMENT COUNT: 1
CONFORMED PERIOD OF REPORT: 20160930
FILED AS OF DATE: 20161004
DATE AS OF CHANGE: 20161004
ISSUER:
COMPANY DATA:
COMPANY CONFORMED NAME: BIOLASE, INC
CENTRAL INDEX KEY: 0000811240
STANDARD INDUSTRIAL CLASSIFICATION: DENTAL EQUIPMENT & SUPPLIES [3843]
IRS NUMBER: 870442441
STATE OF INCORPORATION: DE
FISCAL YEAR END: 1231
BUSINESS ADDRESS:
STREET 1: 4 CROMWELL
CITY: IRVINE
STATE: CA
ZIP: 92618
BUSINESS PHONE: 949-361-1200
MAIL ADDRESS:
STREET 1: 4 CROMWELL
CITY: IRVINE
STATE: CA
ZIP: 92618
FORMER COMPANY:
FORMER CONFORMED NAME: BIOLASE TECHNOLOGY INC
DATE OF NAME CHANGE: 19941117
FORMER COMPANY:
FORMER CONFORMED NAME: LASER MEDICAL TECHNOLOGY INC
DATE OF NAME CHANGE: 19941117
FORMER COMPANY:
FORMER CONFORMED NAME: LASER ENDO TECHNIC CORP
DATE OF NAME CHANGE: 19920708
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: Jack W. Schuler Living Trust
CENTRAL INDEX KEY: 0001661351
STATE OF INCORPORATION: IL
FISCAL YEAR END: 1231
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-36385
FILM NUMBER: 161920360
BUSINESS ADDRESS:
STREET 1: 100 NORTH FIELD DRIVE
STREET 2: SUITE 360
CITY: LAKE FOREST
STATE: IL
ZIP: 60045
BUSINESS PHONE: 224-880-1210
MAIL ADDRESS:
STREET 1: 100 NORTH FIELD DRIVE
STREET 2: SUITE 360
CITY: LAKE FOREST
STATE: IL
ZIP: 60045
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: SCHULER JACK W
CENTRAL INDEX KEY: 0001021412
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-36385
FILM NUMBER: 161920361
MAIL ADDRESS:
STREET 1: 100 N. FIELD DRIVE
STREET 2: SUITE 360
CITY: LAKE FOREST
STATE: IL
ZIP: 60045
4
1
form4.xml
X0306
4
2016-09-30
0000811240
BIOLASE, INC
BIOL
0001021412
SCHULER JACK W
100 N. FIELD DRIVE
SUITE 360
LAKE FOREST
IL
60045
true
0001661351
Jack W. Schuler Living Trust
100 NORTH FIELD DRIVE
SUITE 360
LAKE FOREST
IL
60045
true
Common Stock
2016-09-30
4
C
0
3699100
1.13
A
10195199
I
By Trust
Common Stock
100000
I
By spouse
Series C Participating Convertible Preferred Stock
1.13
2016-09-30
4
C
0
36991
0
D
2016-09-30
Common Stock
3699100
0
I
By Trust
On September 30, 2016, as a result of receipt of the Requisite Stockholder Approval (defined and described further in the Securities Purchase Agreement dated August 1, 2016 and filed as Exhibit 99.1 to the Current Report on Form 8-K filed by the Issuer on August 2, 2016), each share of Preferred Stock (as defined below) automatically converted into 100 shares of Common Stock, reflecting a conversion price equal to $1.13 per share.
The Common Stock is held directly by the Jack W. Schuler Living Trust (the "Trust"). Mr. Schuler serves as sole trustee to the Trust.
Each Reporting Person disclaims beneficial ownership of the Common Stock except to the extent of his or its pecuniary interest therein, and this report shall not be deemed an admission that such Reporting Person is the beneficial owner of the Common Stock for purposes of Section 16 of the Securities Exchange Act of 1934, as amended, or for any other purpose.
These shares of Series C Participating Convertible Preferred Stock ("Preferred Stock") were acquired by the Trust in a privately negotiated transaction with the Issuer, which closed on August 8, 2016.
The Preferred Stock had no expiration date.
The Preferred Stock was held directly by the Trust. Mr. Schuler serves as sole trustee to the Trust.
Each Reporting Person disclaims beneficial ownership of the Preferred Stock except to the extent of his or its pecuniary interest therein, and this report shall not be deemed an admission that such Reporting Person was the beneficial owner of the Preferred Stock for purposes of Section 16 of the Securities Exchange Act of 1934, as amended, or for any other purpose.
This figure has been reduced by 51,438 shares of Common Stock that had been inadvertently included in the shares of Common Stock beneficially owned by the Trust in Mr. Schuler's prior Form 4 filings.
This figure includes an additional 85,200 shares of Common Stock that had been inadvertently excluded from the shares of Common Stock beneficially owned by Mr. Schuler's spouse in Mr. Schuler's prior Form 4 filings.
/s/ Jack Schuler, as self and as Trustee of the Jack W. Schuler Living Trust
2016-10-04