0001209191-17-042884.txt : 20170703 0001209191-17-042884.hdr.sgml : 20170703 20170703174801 ACCESSION NUMBER: 0001209191-17-042884 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20170630 FILED AS OF DATE: 20170703 DATE AS OF CHANGE: 20170703 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: MOLL FREDERIC H CENTRAL INDEX KEY: 0001260157 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-36385 FILM NUMBER: 17945917 MAIL ADDRESS: STREET 1: C/O INTUITIVE SURGICAL INC STREET 2: 950 KIFER ROAD CITY: SUNNYVALE STATE: CA ZIP: 94086 4 1 doc4.xml FORM 4 SUBMISSION X0306 4 2017-06-30 0 0000811240 BIOLASE, INC BIOL 0001260157 MOLL FREDERIC H 4 CROMWELL IRVINE CA 92618 1 0 0 0 Common Stock 2017-06-30 4 C 0 192100 1.24 A 251317 D Series D Participating Convertible Preferred Stock 1.24 2017-06-30 4 C 0 1921 0.00 D 2017-06-30 Common Stock 192100 0 D On June 30, 2017, as a result of receipt of 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), each share of Preferred Stock (as defined below) automatically converted into 100 shares of Common Stock, reflecting a conversion price equal to $1.24 per share. These shares of Series D Participating Convertible Preferred Stock ("Preferred Stock") were acquired by Frederic H. Moll in a private placement with the Issuer, which closed on April 18, 2017. The Preferred Stock had no expiration date. /s/ Michael C. Carroll, attorney-in-fact for Frederic H. Moll 2017-07-03