SEC FORM
3
SEC Form 3
| FORM 3 |
UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES
Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934
or Section 30(h) of the Investment Company Act of 1940
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| OMB APPROVAL |
| OMB Number: |
3235-0104 |
| Estimated average burden |
| hours per response: |
0.5 |
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1. Name and Address of Reporting Person*
| C/O ALIGN TECHNOLOGY, INC. |
| 2560 ORCHARD PARKWAY |
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year)
10/01/2012
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3. Issuer Name and Ticker or Trading Symbol
ALIGN TECHNOLOGY INC
[ ALGN ]
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
|
Director |
|
10% Owner |
| X |
Officer (give title below) |
|
Other (specify below) |
| VP, Global HR |
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5. If Amendment, Date of Original Filed
(Month/Day/Year)
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6. 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 Beneficially Owned |
|---|
| 1. Title of Security (Instr.
4)
|
2.
Amount of Securities Beneficially Owned (Instr.
4)
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3. Ownership Form: Direct (D) or Indirect (I) (Instr.
5)
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4. Nature of Indirect Beneficial Ownership (Instr.
5)
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Table II - Derivative Securities Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
|
|---|
| 1. Title of Derivative Security (Instr.
4)
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2. Date Exercisable and Expiration Date
(Month/Day/Year) |
3. Title and Amount of Securities Underlying Derivative Security (Instr.
4)
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4. Conversion or Exercise Price of Derivative Security
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5. Ownership Form: Direct (D) or Indirect (I) (Instr.
5)
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6. Nature of Indirect Beneficial Ownership (Instr.
5)
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| Date Exercisable |
Expiration Date |
Title |
Amount or Number of Shares |
| Explanation of Responses: |
| No securities are beneficially owned. |
|
Roger E. George, Atty-in-Fact for Jennifer Erfurth |
10/09/2012 |
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** Signature of Reporting Person |
Date |
| Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. |
| * If the form is filed by more than one reporting person,
see
Instruction
5
(b)(v). |
| ** 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 is insufficient,
see
Instruction 6 for procedure. |
| Persons who respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB Number. |
LIMITED POWER OF ATTORNEY - SECURITIES LAW COMPLIANCE
The undersigned, as an officer or director of Align
Technology, Inc. (the "Company"), hereby constitutes and
appoints Roger E. George and Keneth B. Arola, and each
of them, the undersigned's true and lawful
attorney-in-fact and agent to complete and execute
such Forms 144, Forms 3, 4 and 5 and other forms as
such attorney shall in his discretion determine to
be required or advisable pursuant to Rule 144 promulgated
under the Securities Act of 1933 (as amended), Section
16 of the Securities Exchange Act of 1934 (as amended)
and the rules and regulations promulgated thereunder,
or any successor laws and regulations, as a consequence
of the undersigned's ownership, acquisition or disposition
of securities of the Company, and to do all acts necessary
in order to file such forms with the Securities and
Exchange Commission, any securities exchange or
national association, the Company and such other
person or agency as the attorney shall deem appropriate.
The undersigned hereby ratifies and
confirms all that said attorneys-in-fact and agents shall
do or cause to be done by virtue hereof.
This Limited Power of Attorney shall remain in full
force and effect until the undersigned is no longer required
to file Forms 3, 4 and 5 with respect to the undersigned's
holdings of and transactions in securities issued by the
Company unless earlier revoked by the undersigned in a
writing delivered to the foregoing attorneys-in-fact.
This Limited Power of Attorney is executed at Mountain
View, CA, as of the date set forth below.
/s/Jennifer M. Erfurth
Jennifer M. Erfurth
Dated: 10/03/12
Witness:
/s/Yvonne Valiquette
Yvonne Valiquette
Type or Print Name
Dated: 10/03/12
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