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