SEC Form 4 · accession 0001209191-16-144507
BIOLASE, INC · BIOL
Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗
Reporting owner
Jonathan T Lord M.D.
Director
Period of report
Sep 30, 2016
Accepted (ET)
Oct 4, 2016 · 5:26 pm EDT
Rule 10b5-1 plan
unknown — predates the checkbox
Issuer CIK
0000811240
Table I — non-derivative securities
| Security | Date | Code | Shares | Price | A/D | Owned after | D/I | Nature of ownership |
|---|---|---|---|---|---|---|---|---|
| Common StockF1 | Sep 30, 2016 | C | 177,000 | $1.13 | A | 303,690 | D |
Table II — derivative securities
| Security | Conv. / exercise price | Date | Code | Shares | A/D | Exercisable | Expires | Underlying | Underlying shares | Owned after | D/I |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Series C Participating Convertible Preferred StockF2,F3 | $1.13 | Sep 30, 2016 | C | 1,770 | D | Sep 30, 2016 | — | Common Stock | 177,000 | 0 | D |
Explanation of responses
- F1On September 30, 2016, as a result of receipt of the Requisite Stockholder Approval (defined and described further in the Securities Purchase Agreement dated August 1, 2016 and filed as Exhibit 99.1 to the Current Report on Form 8-K filed by the Issuer on August 2, 2016), each share of Preferred Stock (as defined below) automatically converted into 100 shares of Common Stock, reflecting a conversion price equal to $1.13 per share.
- F2These shares of Series C Participating Convertible Preferred Stock ("Preferred Stock") were acquired by Jonathan T. Lord in a private placement with the Issuer, which closed on August 8, 2016.
- F3The Preferred Stock had no expiration date.