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OMB APPROVAL
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OMB Number 3235-0362
Expires: September 30, 1998
Estimated average burden
hours per response ....... 1.0
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U.S. SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
FORM 5
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
[ ] Check this box if no longer subject of 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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1. Name and Address of Reporting Person
Gerald A. Poch
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(Last) (First) (Middle)
c/o Pequot Capital Management, Inc.
500 Nyala Farm Road
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(Street)
Westport CT 06880
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(City) (State) (Zip)
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2. Issuer Name and Ticker or Trading Symbol
BriteSmile, Inc.
BSML
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3. IRS or Social Security Number of Reporting Person (Voluntary)
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4. Statement for Month/Year
12/31/2000
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5. If Amendment, Date of Original (Month/Year)
2/14/01
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6. Relationship of Reporting Person to Issuer
(Check all applicable)
[ X ] Director [ ] 10% Owner
[ ] Officer (give title below) [ ] Other (specify below)
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7. Individual or Joint/Group Filing
(Check Applicable Line)
[ X ] Form filed by One Reporting Person
[ ] Form filed by More than One Reporting Person
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Table I -- Non-Derivative Securities Acquired, Disposed of,
or Beneficially Owned
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5. 6.
4. Amount of Owner-
Security Acquired (A) or Securities ship
Disposed of (D) Beneficially Form: 7.
(Instr. 3, 4 and 5) Owned at End Direct Nature of
2. 3. ----------------------------- of Issuer's (D) or Indirect
1. Transaction Transaction (A) Fiscal Year Indirect Beneficial
Title of Security Date Code Amount or Price (Instr. 3 (I) Ownership
(Instr. 3) (mm/dd/yy) (Instr. 8) (D) & 4) (Instr.4) (Instr. 4)
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None
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Reminder: Report on a separate line for each class of securities beneficially
owned directly or indirectly
FORM 5 (continued)
Table II -- Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
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9. 10.
Number Owner-
of ship
2. Deriv- of
Conver- 5. 7. ative Deriv- 11.
sion Number of Title and Amount Secur- ative Nature
or Derivative 6. of Underlying 8. ities Secur- of
Exer- Securities Date Securities Price Bene- ity: In-
cise 3. Acquired (A) Exercisable and (Instr. 3 and 4) of ficially Direct direct
Price Trans- 4. or Disposed Expiration Date ---------------- Deriv- Owned (D) or Bene-
1. of action Trans- of (D) (Month/Day/Year) Amount ative at End In- ficial
Title of Deriv- Date action (Instr. 3, ---------------- or Secur- of direct Owner-
Derivative ative (Month/ Code 4 and 5) Date Expira- Number ity Year (I) ship
Security Secur- Day/ (Instr. ------------ Exer- tion of (Instr. (Instr. (Instr. (Instr.
(Instr. 3) ity Year) 8) (A) (D) cisable Date Title Shares 5) 4) 4) 4)
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CONVERT- $6.18/SH 6/30/00 P $1,166,667 IMMED 06/29/05 COMMON 188,782 $6.18/SH 188,782 (I) BY PARTNER
IBLE NOTES (2) (1)(2) STOCK (1)(2) (1)(2) (1) -SHIP
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CONVERT- $6.18/SH 8/03/00 P $3,000,000 IMMED 08/03/05 COMMON 485,436 $6.18/SH 485,436 (I) BY PARTNER
IBLE NOTES (2) (1)(2) STOCK (1)(2) (1)(2) (1) -SHIP
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WARRANT $7.21/SH 6/30/00 P 94,391 IMMED 06/29/05 COMMON 94,391 $0 94,391 (I) BY PARTNER
(1) STOCK (1) (1) (1) -SHIP
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WARRANT $7.21/SH 8/03/00 P 242,717 IMMED 08/03/05 COMMON 242,717 $0 242,717 (I) BY PARTNER
(1) STOCK (1) (1) (1) -SHIP
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OPTIONS $9.25/SH 3/24/00 A 20,000 IMMED 03/24/10 COMMON 20,000 $0 20,000 (I) BY PARTNER
(1) (3) STOCK (1) (1) (1) -SHIP
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Explanation of Responses:
(1) The reporting person is an employee of Pequot Capital Management, Inc. The
reporting person disclaims beneficial ownership of these securities, except
to the extent of his pecuniary interest.
(2) The Convertible Note is convertible at the option of the holder into units
consisting of convertible subordinated notes to purchase shares of the
Issuer's common stock. The convertible subordinated notes are, in turn,
convertible into shares of common stock of the Issuer at a conversion price
of $6.18.
(3) The options vest 50% immediately, then another 50% on the date which is six
months after the date of the grant.
/s/ Gerald A. Poch 08/10/2001
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**Signature of Reporting Person Date
** Intentional misstatements or omissions of facts constitute Federal Criminal
Violations.
See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a).
Note: File three copies of this Form, one of which must be manually signed.
If space provided is insufficient, see Instruction 6 for procedure.