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F O R M 5
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U.S. SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP
Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934,
Section 17(a) of the Public Utility Holding Company Act of 1935 or
Section 30(f) of the Investment Company Act of 1940
[ ] Check this box if no longer subject to Section 16. Form 4 or Form 5
obligations may continue. See Instruction 1(b).
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1. Name and Address of Reporting Person*
Mann Robert K.
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(Last) (First) (Middle)
17 Tripp Road
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(Street)
Woodstock, CT 06261
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(City) (State) (Zip)
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2. Issuer Name and Ticker of Trading Symbol
BioLase Technology, Inc. (BLTI)
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3. IRS or Social Security Number of Reporting Person (Voluntary)
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4. Statement for Month/Year
December 1997
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5. If Amendment, Date of Original (Month/Year)
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6. Relationship of Reporting Person to Issuer (Check all applicable)
[ ] Director*
[X] 10% Owner
[ ] Officer (give title below)
[ ] Other (specify below)
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7. Individual or Joint/Group Reporting (Check all applicable)
[X] Form Filed by One Reporting Person
[ ] Form Filed by More than One Reporting Person
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<TABLE>
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TABLE I -- NON-DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF, OR BENFICIALLY OWNED
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1. Title of Security (Instr. 3) 2. Transaction Date 3. Transaction Code 4. Securities Acquired (A)
(Month/Day/Year) (Instr. 8) or Disposed of (D)
(Instr. 3, 4 and 5)
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(A) or
Code V Amount (D) Price
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<S> <C> <C> <C> <C> <C> <C>
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</TABLE>
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<TABLE>
<CAPTION>
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TABLE I -- NON-DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF, OR BENFICIALLY OWNED -- Continued
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1. Title of Security (Instr. 3) 5. Amount of Securities 6. Ownership Form: 6. Nature of Indirect
Beneficially Owned At Direct (D) or Beneficial
End of Issuer's Fiscal Indirect (I) Ownership
Year (Inst. 3 and 4) (Instr. 4) (Instr. 4)
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<S> <C> <C> <C>
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</TABLE>
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<TABLE>
<CAPTION>
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TABLE II -- DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF, OR BENEFICIALLY OWNED
(E.G., PUTS, CALLS, WARRANTS, OPTION, CONVERTIBLE SECURITIES)
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1. Title of Derivative Security 2. Conversion 3. Transaction Date 4. Transaction Code 5. Number of Derivative
(Instr. 3) Of Exercise (Month/Day/Year) (Instr. 8) Securities Acquired (A)
Price of or Disposed of (D)
Derivative (Instr. 3, 4, and 5)
Security
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Code V (A) (D)
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<S> <C> <C> <C> <C> <C> <C>
Stock Purchase Warrants 3.50 10/16/96 3 10,000
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Stock Purchase Warrants 3.50 10/16/96 3 5,000
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</TABLE>
<TABLE>
<CAPTION>
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TABLE II -- DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF, OR BENEFICIALLY OWNED
(E.G., PUTS, CALLS, WARRANTS, OPTION, CONVERTIBLE SECURITIES) -- Continued
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1. Title of Derivative Security 6. Date 7. Title and 8. Price of
(Instr. 3) Exercisable Amount of Derivavtive
and Underlying Security
Expiration Securities (Instr. 5)
Date (Month/ (Instr. 3
Day/Year) and 4)
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Date Expira- Amount or
Exer- tion Number
cisable Date Title of Shares
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<S> <C> <C> <C> <C> <C>
Stock Purchase Warrants* * 12/31/98 Common Stock 10,000 *
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Stock Purchase Warrants* * 12/31/98 Common Stock 5,000 *
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</TABLE>
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<TABLE>
<CAPTION>
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TABLE II -- DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF, OR BENEFICIALLY OWNED
(E.G., PUTS, CALLS, WARRANTS, OPTION, CONVERTIBLE SECURITIES) -- Continued
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1. Title of Derivative Security 9. Number of Derivative 10. Ownership of 11. Nature of Indirect
(Instr. 3) Securities Beneficially Derivative Security: Beneficial
Owned at End of Year Direct (D) or Ownership
(Instr. 4) Indirect (I) (Instr. 4) (Instr. 4)
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<S> <C> <C> <C>
Stock Purchase Warrants 191,365 D
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Stock Purchase Warrants 191,365 I *
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In connection with a Reg. D offering closed on 10/16/98, the Issuer issued (i)
to the Reporting Person directly and (ii) 1 Unit to Trust Company of America
f/b/o the Reporting Person and his spouse, Sharon Mann. Each Unit cost $50,000
anda consisted of one share of Series A Redeemable Cumulative Preferred Stock
and 5,000 Redeemable Stock Purchase Warrants. These warrants were issued in
addition to the 176,365 warrants in which the Reporting Person has a pecuniary
interest and which were reported in the Reporting Person's Form 3 dated
11/14/96. The warrants reported above were inadvertently omitted from the
1/14/96 Form 3. One-third of the warrants reported above vested and became
exercisable on 2/13/97, 6/13/97, and 10/16/97, respectively.
/s/Robert K. Mann 2/13/98
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Signature of Reporting Person Date
