0001209191-17-027583.txt : 20170419 0001209191-17-027583.hdr.sgml : 20170419 20170419193613 ACCESSION NUMBER: 0001209191-17-027583 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: CLARK PAUL N CENTRAL INDEX KEY: 0001222248 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-36385 FILM NUMBER: 17771074 MAIL ADDRESS: STREET 1: 5301 STEVENS CREEK BLVD STREET 2: MS 1A-LC CITY: SANTA CLARA STATE: CA ZIP: 95051 4 1 doc4.xml FORM 4 SUBMISSION X0306 4 2017-04-18 0 0000811240 BIOLASE, INC BIOL 0001222248 CLARK PAUL N 4 CROMWELL IRVINE CA 92603 1 0 0 0 Series D Participating Convertible Preferred Stock 2017-04-18 4 P 0 1536 124.00 A Common Stock 156300 1536 I By Trust Warrants (right to buy) 1.80 2017-04-18 4 P 0 76089 0.125 A 2017-10-18 2022-04-18 Common Stock 76089 76089 I By Trust These shares of Series D Participating Convertible Preferred Stock ("Preferred Stock") and Warrants were acquired by Paul and Carolyn Clark Revocable Trust of 2009 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. The Series D Participating Preferred Stock is held directly by held by the Paul and Carolyn Clark Revocable Trust of 2009. Mr. Clark is the trustee of the Paul and Carolyn Clark Revocable Trust of 2009. The Reporting Person disclaims beneficial ownership of the Preferred Stock and Warrants except to the extent of his pecuniary interest therein, and this report shall not be deemed an admission that the Reporting Person is the beneficial owner of the Preferred Stock or Warrants for purposes of Section 16 of the Securities Exchange Act of 1934, as amended, or for any other purpose. /s/ Michael C. Carroll, attorney-in-fact for Paul N. Clark 2017-04-19