0001209191-21-053035.txt : 20210823 0001209191-21-053035.hdr.sgml : 20210823 20210823191217 ACCESSION NUMBER: 0001209191-21-053035 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20210812 FILED AS OF DATE: 20210823 DATE AS OF CHANGE: 20210823 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Summerhays Carol Gomez DDS CENTRAL INDEX KEY: 0001879372 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-36385 FILM NUMBER: 211198176 MAIL ADDRESS: STREET 1: 27042 TOWN CENTRE DRIVE STREET 2: SUITE 270 CITY: FOOTHILL RANCH STATE: CA ZIP: 92610 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 4 1 doc4.xml FORM 4 SUBMISSION X0306 4 2021-08-12 0 0000811240 BIOLASE, INC BIOL 0001879372 Summerhays Carol Gomez DDS 27042 TOWNE CENTRE DR. SUITE 270 FOOTHILL RANCH CA 92610 1 0 0 0 Stock Appreciation Right 0.63 2021-08-12 4 A 0 98955 0.00 A 2031-08-12 Common Stock 98955 98955 D Of the stock appreciation rights subject to this SAR, the stock appreciation rights vest on May 26, 2022. /s/ Michael C. Carroll, attorney-in-fact for Carol G. Summerhays 2021-08-22