0001209191-16-144507.txt : 20161004
0001209191-16-144507.hdr.sgml : 20161004
20161004172657
ACCESSION NUMBER: 0001209191-16-144507
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: LORD JONATHAN T MD
CENTRAL INDEX KEY: 0001112980
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-36385
FILM NUMBER: 161920241
MAIL ADDRESS:
STREET 1: 500 WEST MAIN ST.
CITY: LOUISVILLE
STATE: KY
ZIP: 40202
4
1
doc4.xml
FORM 4 SUBMISSION
X0306
4
2016-09-30
0
0000811240
BIOLASE, INC
BIOL
0001112980
LORD JONATHAN T MD
4 CROMWELL
IRVINE
CA
92618
1
0
0
0
Common Stock
2016-09-30
4
C
0
177000
1.13
A
303690
D
Series C Participating Convertible Preferred Stock
1.13
2016-09-30
4
C
0
1770
0.00
D
2016-09-30
Common Stock
177000
0
D
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.
These shares of Series C Participating Convertible Preferred Stock ("Preferred Stock") were acquired by Jonathan T. Lord in a private placement with the Issuer, which closed on August 8, 2016.
The Preferred Stock had no expiration date.
/s/ Michael C. Carroll, attorney-in-fact for Jonathan T. Lord
2016-10-04