0001209191-17-042885.txt : 20170703
0001209191-17-042885.hdr.sgml : 20170703
20170703174934
ACCESSION NUMBER: 0001209191-17-042885
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: Flynn Harold C Jr.
CENTRAL INDEX KEY: 0001647860
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-36385
FILM NUMBER: 17945921
MAIL ADDRESS:
STREET 1: 4 CROMWELL
CITY: IRVINE
STATE: CA
ZIP: 92618
4
1
doc4.xml
FORM 4 SUBMISSION
X0306
4
2017-06-30
0
0000811240
BIOLASE, INC
BIOL
0001647860
Flynn Harold C Jr.
C/O 4 CROMWELL
IRVINE
CA
92618
1
1
0
0
President and CEO
Common Stock
2017-06-30
4
C
0
30700
1.24
A
66100
I
By Trust
Common Stock
96720
D
Series D Participating Convertible Preferred Stock
1.24
2017-06-30
4
C
0
307
0.00
D
2017-06-30
Common Stock
30700
0
I
By Trust
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.
The Common Stock is held directly by the Flynn Living Trust (the "Trust"). Mr. Flynn serves as a co-trustee to the Trust and his daughter is the beneficiary of the Trust.
These shares of Series D Participating Convertible Preferred Stock ("Preferred Stock") were acquired by the Trust in a private placement with the Issuer, which closed on April 18, 2017.
The Preferred Stock had no expiration date.
The Preferred Stock was held directly by the Trust. Mr. Flynn serves as a co-trustee to the Trust and his daughter is the beneficiary of the Trust.
The Reporting Person disclaims beneficial ownership of the Preferred Stock 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 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 Harold C. Flynn, Jr.
2017-07-03