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. |
2650 ORCHARD PARKWAY |
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year) 04/29/2011
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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)
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Director |
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10% Owner |
X |
Officer (give title below) |
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Other (specify below) |
SVP, Bus. Development |
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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 |
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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)
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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)
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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. |
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Roger E. George, Atty-in-Fact for Timothy A. Mack |
05/02/2011 |
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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 of Align Technology, Inc. (the "Company"),
hereby constitutes and appoints Roger E. George and Kenneth B. Arola, and
each of them, the undersigned's tru 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 or her 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.
The Limited Power of Attorney is executed in New Jersey, as of the date
set forth below.
/s/Timothy A. Mack
April 26, 2011
Witness:
/s/ Robin Lee Seasock
April 26. 2011