0001209191-17-027580.txt : 20170419
0001209191-17-027580.hdr.sgml : 20170419
20170419193441
ACCESSION NUMBER: 0001209191-17-027580
CONFORMED SUBMISSION TYPE: 4
PUBLIC DOCUMENT COUNT: 1
CONFORMED PERIOD OF REPORT: 20170418
FILED AS OF DATE: 20170419
DATE AS OF CHANGE: 20170419
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: Nelson Mark Joseph
CENTRAL INDEX KEY: 0001435748
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-36385
FILM NUMBER: 17771070
MAIL ADDRESS:
STREET 1: 13601 NORTH FREEWAY, SUITE 200
CITY: FORT WORTH
STATE: TX
ZIP: 76177
4
1
doc4.xml
FORM 4 SUBMISSION
X0306
4
2017-04-18
0
0000811240
BIOLASE, INC
BIOL
0001435748
Nelson Mark Joseph
C/O 4 CROMWELL
IRVINE
CA
92618
0
1
0
0
SVP & Chief Financial Officer
Series D Participating Convertible Preferred Stock
2017-04-18
4
P
0
192
124.00
A
Common Stock
19200
192
D
Warrants (right to buy)
1.80
2017-04-18
4
P
0
9346
0.125
A
2017-10-18
2022-04-18
Common Stock
9346
9346
D
These shares of Series D Participating Convertible Preferred Stock ("Preferred Stock") and Warrants were acquired by Mark J. Nelson in a private placement with the Issuer that closed on April 18, 2017 (the "Closing").
Each share of Preferred Stock will initially be convertible into 100 shares of Common Stock ("Shares"), reflecting a conversion price equal to $1.24 per Share. The conversion of the Preferred Stock will occur automatically upon the Requisite Stockholder Approval (defined and described further in the Securities Purchase Agreement dated April 11, 2017 and filed as Exhibit 99.1 to the Current Report on Form 8-K filed by the Issuer on April 14, 2017), which is expected to occur after the Closing. The Preferred Stock has no expiration date.
/s/ Michael C. Carroll, attorney-in-fact for Mark J. Nelson
2017-04-19