0001209191-14-048730.txt : 20140723 0001209191-14-048730.hdr.sgml : 20140723 20140723201703 ACCESSION NUMBER: 0001209191-14-048730 CONFORMED SUBMISSION TYPE: 3 PUBLIC DOCUMENT COUNT: 2 CONFORMED PERIOD OF REPORT: 20140612 FILED AS OF DATE: 20140723 DATE AS OF CHANGE: 20140723 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: CLARK PAUL N CENTRAL INDEX KEY: 0001222248 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-36385 FILM NUMBER: 14989785 MAIL ADDRESS: STREET 1: 5301 STEVENS CREEK BLVD STREET 2: MS 1A-LC CITY: SANTA CLARA STATE: CA ZIP: 95051 3 1 doc3.xml FORM 3 SUBMISSION X0206 3 2014-06-12 0 0000811240 BIOLASE, INC BIOL 0001222248 CLARK PAUL N 4 CROMWELL IRVINE CA 92603 1 0 0 0 Common Stock, par value $0.001 per share 85121 I By trust Stock Option (right to buy) 2.03 2024-06-12 Common Stock 23750 D The stock option is immediately exercisable for all of the option shares. However, any shares purchased under such option are subject to repurchase by the Issuer, at the lower of the exercise price paid per share or the fair market value per share (determined at the time of repurchase), should the Reporting Person cease Board service prior to vesting of those shares. The shares vest, and the Issuer's right of repurchase lapses, in four successive quarterly installments upon the Reporting Person's completion of each quarter of service as a non-employee director measured from the grant date. The shares subject to the option grant will immediately vest in full if certain changes in control or ownership occur or if the Reporting Person dies or becomes disabled while serving as a director. /s/ Michael C. Carroll, attorney-in-fact for Paul N. Clark. 2014-07-23 EX-24.3_532363 2 poa.txt POA DOCUMENT LIMITED POWER OF ATTORNEY Know all by these presents, that the undersigned hereby authorizes Michael C. Carroll to execute for and on behalf of the undersigned, in the undersigned's capacity as a Section 16 reporting person of Biolase, Inc., a Delaware corporation (the "Company"), EDGAR Form ID (including amendments thereto) and Authenticating Statements, Forms 3, 4 and 5, and any amendments thereto, and cause such form(s) to be filed with the United States Securities and Exchange Commission and The NASDAQ Stock Market. The undersigned hereby grants to such attorney-in-fact full power and authority to do and perform any and every act and thing whatsoever requisite, necessary, or proper to be done in exercise of any of the rights and powers herein granted, as fully to all intents and purposes as the undersigned might or could do if personally present, with full power of substitution or revocation, hereby ratifying and confirming all that such attorney-in-fact, or such attorney-in-fact's substitute or substitutes, shall lawfully do or cause to be done by virtue of this power of attorney and the rights and powers herein granted. The undersigned acknowledges that the foregoing attorney-in-fact, in serving in such capacity at the request of the undersigned, is not assuming, nor is the Company assuming, any of the undersigned's responsibilities to comply with Section 16 of the Securities Exchange Act of 1934, as amended or the rules promulgated thereunder. This Limited Power of Attorney shall remain in full force and effect until the undersigned is no longer required to file Forms 3, 4 and 5 with respect to the undersigned's holdings of, and transactions in, securities issued by the Company, unless earlier revoked by the undersigned in a signed writing delivered to the foregoing attorney-in-fact. IN WITNESS WHEREOF, the undersigned has cause this Power of Attorney to be executed as of this 7th day of March, 2014. By: /s/ Paul N. Clark Print Name: Paul N. Clark