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F O R M 5
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[ ] Check box if no longer subject to Section 16. Form 4 or Form 5
obligations may continue. See Instruction 1(b).
[ ] Form 3 Holdings Reported
[x] Form 4 Transactions Reported
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OMB APPROVAL
OMB Number
Expires:
Estimated Average Burden
hours per response . . . . . .
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U.S. SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
ANNUAL 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
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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 06281
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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 1998
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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>
<CAPTION>
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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
Amount (D) Price
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<S> <C> <C> <C> <C> <C>
Common Stock, $.001 par value 5/12/98 P4 50,000 A 150,000
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</TABLE>
*If the form is filed by more than one reporting person, see instruction 4(b)(v)
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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: 7. 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>
Common Stock, $.001 par value 1,267,440 I (1)
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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, OPTIONS, 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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(A) (D)
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<S> <C> <C> <C> <C> <C> <C>
Stock Purchase Warrants 3.75 5/12/98 P4 A
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Stock Purchase Warrants 3.75 5/12/98 P4 A
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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 5/12/98 4/31/00 Common Stock 25,000 (1)
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Stock Purchase Warrants 5/12/98 4/31/00 Common Stock 22,500 (2)
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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 508,865 I
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Stock Purchase Warrants 508,865 I
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</TABLE>
Explanation of Responses:
(1) In connection with a Reg. D offering closed on 10/16/98 (the "Offering"),
the Issuer issued 5 units (described below) to PAC Capital Strategies Limited
Partnership (the "Partnership"). The reporting person is a principal stockholder
of the sole shareholder of the Partnership's general partner, Advisor's Capital
Investments, Inc. Each Unit cost $30,000 and consisted of 10,000 shares of the
Issuer's Common Stock, $.001 par value and warrants to purchase an additional
5,000 shares of the Issuer's Common Stock.
(2) The reporting person is a principal of PacVest Associates, Inc., a
registered broker-dealer ("PacVest"). As part of its compensation for its
services as placement agent for the above-referenced Offerings, PacVest was
granted warrants to purchase 22,500 shares of the Issuer's Common Stock.
/s/Robert K. Mann 2/12/99
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Signature of Reporting Person Date
**Intentional misstatements or ommissions of facts constitute Federal Criminal
Violations. See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a).
Potential persons who are to respond to the collection of information contained
in this form are not required to respond unless the form displays a currently
valid OMB number.
