Attached files
file | filename |
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EX-99.8 - EX-99.8 - BIOLASE, INC | d463255dex998.htm |
EX-99.7 - EX-99.7 - BIOLASE, INC | d463255dex997.htm |
EX-99.6 - EX-99.6 - BIOLASE, INC | d463255dex996.htm |
EX-99.4 - EX-99.4 - BIOLASE, INC | d463255dex994.htm |
EX-99.3 - EX-99.3 - BIOLASE, INC | d463255dex993.htm |
EX-99.2 - EX-99.2 - BIOLASE, INC | d463255dex992.htm |
EX-99.1 - EX-99.1 - BIOLASE, INC | d463255dex991.htm |
EX-4.8 - EX-4.8 - BIOLASE, INC | d463255dex48.htm |
S-1/A - S-1/A - BIOLASE, INC | d463255ds1a.htm |
Exhibit 99.5
FORM OF NOMINEE HOLDER CERTIFICATION FORM
The undersigned, a bank, broker, trustee, depositary or other nominee of non-transferable subscription rights (the Rights) to purchase shares of common stock, par value $0.001 per share (the Common Stock), of BIOLASE, Inc. (the Company) pursuant to the rights offering (the Rights Offering) described and provided for in the Companys Prospectus dated [●], 2017 (the Prospectus), hereby certifies to the Company and to Computershare Inc., as subscription agent for the Rights Offering (the Subscription Agent), that (1) the undersigned has exercised, on behalf of the beneficial owners thereof (which may include the undersigned), on the terms and subject to the conditions set forth in the Prospectus, the number of Rights specified below to purchase the number of shares of Common Stock specified below pursuant to the Basic Subscription Right (as defined in the Prospectus) and, on behalf of beneficial owners of Rights who have subscribed for the purchase of additional shares of Common Stock pursuant to the Over-Subscription Privilege (as defined in the Prospectus), the number of shares specified below pursuant to the Over-Subscription Privilege, listing separately below each such exercised Basic Subscription Right and the corresponding Over-Subscription Privilege (without identifying any such beneficial owner by name) and (2) to the extent a beneficial owner has elected to subscribe for shares pursuant to the Over-Subscription Privilege, each such beneficial owners Basic Subscription Right has been timely exercised in full.
Number of Rights Held |
Number of Rights Exercised |
Number of Shares Subscribed for Pursuant to Basic Subscription Right |
Number of Shares Subscribed for Pursuant to Over- Subscription Privilege |
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[Certification continues on the following page]
Provide the following information, if applicable:
Name of Nominee Holder | DTC Participant Number | |||||||
By: | ||||||||
DTC Subscription Confirmation Numbers | ||||||||
Name: | ||||||||
Title: | ||||||||
Phone Number: | ||||||||
Fax Number: | ||||||||
Dated |