SEC Form 4 · accession 0001209191-17-027580
BIOLASE, INC · BIOL
Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗
Reporting owner
Mark Joseph Nelson
Officer — SVP & Chief Financial Officer
Period of report
Apr 18, 2017
Accepted (ET)
Apr 19, 2017 · 7:34 pm EDT
Rule 10b5-1 plan
unknown — predates the checkbox
Issuer CIK
0000811240
Table I — non-derivative securities
No Table I lines on this filing.
Table II — derivative securities
| Security | Conv. / exercise price | Date | Code | Shares | A/D | Exercisable | Expires | Underlying | Underlying shares | Owned after | D/I |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Series D Participating Convertible Preferred StockF1,F2 | — | Apr 18, 2017 | P | 192 | A | — | — | Common Stock | 19,200 | 192 | D |
| Warrants (right to buy)F1 | $1.80 | Apr 18, 2017 | P | 9,346 | A | Oct 18, 2017 | Apr 18, 2022 | Common Stock | 9,346 | 9,346 | D |
Explanation of responses
- F1These 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").
- F2Each 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.