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