SEC 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
|Estimated average burden|
|hours per response:
1. Name and Address of Reporting Person*
|C/O ALIGN TECHNOLOGY INC.|
|2560 ORCHARD PARKWAY|
2. Date of Event Requiring Statement
3. Issuer Name and Ticker or Trading Symbol
ALIGN TECHNOLOGY INC
[ ALGN ]
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
||Officer (give title below)
||Other (specify below)
5. If Amendment, Date of Original Filed
6. Individual or Joint/Group Filing (Check Applicable Line)
||Form filed by One Reporting Person
||Form filed by More than One Reporting Person
|Table I - Non-Derivative Securities Beneficially Owned|
|1. Title of Security (Instr.
Amount of Securities Beneficially Owned (Instr.
||3. Ownership Form: Direct (D) or Indirect (I) (Instr.
||4. Nature of Indirect Beneficial Ownership (Instr.
Table II - Derivative Securities Beneficially Owned|
(e.g., puts, calls, warrants, options, convertible securities)
|1. Title of Derivative Security (Instr.
||2. Date Exercisable and Expiration Date
||3. Title and Amount of Securities Underlying Derivative Security (Instr.
||4. Conversion or Exercise Price of Derivative Security
||5. Ownership Form: Direct (D) or Indirect (I) (Instr.
||6. Nature of Indirect Beneficial Ownership (Instr.
||Amount or Number of Shares
|Explanation of Responses:|
|No securities are beneficially owned.|
||Roger E. George Atty-in-Fact for Kevin J. Dallas
||** Signature of Reporting Person
|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,
|** Intentional misstatements or omissions of facts constitute Federal Criminal Violations
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,
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 Yvonne R. Valiquette 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
Redmond, Washington, as of the date set forth below.
/s/Kevin J. Dallas
Kevin J. Dallas
/s/ Miles F. Holden
Miles F. Holden