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F O R M 4
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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).
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OMB APPROVAL
OMB Number 3235-0287
Expires: September 30, 1998
Estimated Average Burden
hours per response . . . . . . 0.5
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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
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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.
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3. IRS or Social Security Number of Reporting Person (Voluntary)
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4. Statement for Month/Year
June 1999
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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 filing (Check Appropriate Line)
[X] Form filed by One Reporting Person
[ ] Form filed by More Than One Reporting Person
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*If the form is filed by more than one 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
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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>
Common Stock 6/18/99 S 13,700 D $2.77
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Common Stock 6/21/99 S 4,482 D $2.75
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Common Stock 6/22/99 S 8,182 D $2.75
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Common Stock 6/23/99 S 4,000 D $2.75
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Common Stock 6/24/99 S 3,000 D $2.75
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Common Stock 6/30/99 S 3,000 D $2.75
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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: 7. Nature of Indirect
Beneficially Owned Direct (D) or Beneficial
at End of Month Indirect (I) Ownership
(Instr. 3 and 4) (Instr. 4) (Instr. 4)
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<S> <C> <C> <C>
Common Stock 18,182 D
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Common Stock 18,182 D
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Common Stock 18,182 D
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Common Stock 18,182 D
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Common Stock 18,182 D
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Common Stock 18,182 D
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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) Or 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>
</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>
</TABLE>
<PAGE>
<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 Form of 11. Nature of Indirect
(Instr. 3) Securities Beneficially Derivative Security: Beneficial
Owned at End of Month Direct (D) or Ownership
(Instr. 4) Indirect (I) (Instr. 4) (Instr. 4)
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<S> <C> <C> <C>
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</TABLE>
Explanation of Responses:
/s/ Robert K. Mann 7-12-99
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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.
