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
|
| 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 DENTSPLY SIRONA INC |
| 13320 BALLANTYNE CORPORATE PLACE |
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year)
09/12/2022
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3. Issuer Name and Ticker or Trading Symbol
DENTSPLY SIRONA Inc.
[ XRAY ]
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
| X |
Director |
|
10% Owner |
| X |
Officer (give title below) |
|
Other (specify below) |
| President, CEO & Member of BOD |
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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)
|
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: |
| Remarks: |
|
| No securities are beneficially owned. |
|
/s/ Dane Baumgardner, Attorney-In-Fact for Simon D. Campion |
09/19/2022 |
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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. |
DENTSPLY SIRONA Inc.
Limited Power of Attorney for Section 16 Reporting Obligations
Know all by these presents that the undersigned hereby constitutes and
appoints each of Cheree H. Johnson, and Dane Baumgardner, or either of
them acting singly and with full power of substitution, the undersigned's
true and lawful attorney-in-fact to:
1. Execute for and on behalf of the undersigned, in the
undersigned's capacity as an officer or director or both of DENTSPLY
SIRONA Inc. (the "Company"), Forms 3, 4 and 5 (and any amendments
thereto) in accordance with Section 16(a) of the Securities Exchange Act
of 1934, as amended (the "Exchange Act"), and the rules thereunder;
2. To perform any and all acts for and on behalf of the
undersigned which may be necessary or desirable to complete and execute
any such Forms 3, 4 or 5, complete and execute any amendments thereto,
and timely file such forms with the U.S. Securities and Exchange
Commission (the "SEC") and any securities exchange or similar authority,
including without limitation the filing of a Form ID or any other
documents necessary or appropriate to enable the undersigned to file the
Forms 3, 4 and 5 electronically with the SEC;
3. Seek or obtain, as the undersigned's representative and on the
undersigned's behalf, information on transactions in the Company's
securities from any third party, including brokers, employee benefit plan
administrators and trustees, and the undersigned hereby authorizes any
such person to release any such information to each of the undersigned's
attorneys-in-fact appointed by this Limited Power of Attorney and
approves and ratifies any such release of information;
4. Take any other action in connection with the foregoing which,
in the opinion of such attorney-in-fact, may be of benefit to, in the
best interest of, or legally required by or for, the undersigned, it
being understood that the documents executed by such attorney-in-fact on
behalf of the undersigned pursuant to this Limited Power of Attorney
shall be in such form and shall contain such information and disclosure
as such attorney-in-fact may approve in such attorney-in-fact's
discretion.
The undersigned hereby grants to each such attorney-in-fact full
power and authority to do and perform any and every act and thing
whatsoever required, necessary or proper to be done in the exercise of
any of the rights and powers herein granted, as fully to all intents and
purposes as the undersigned might or could do if personally present, with
full power of substitution or revocation, hereby ratifying and confirming
all that such attorney-in-fact, or such attorney-in-fact's substitute or
substitutes, shall lawfully do or cause to be done by virtue of this
Limited Power of Attorney and the rights and powers herein granted.
The undersigned acknowledges that the foregoing attorneys-in-
fact, in serving in such capacity at the request and on the behalf of the
undersigned, are not assuming, nor is the Company assuming, any of the
undersigned's responsibilities to comply with, or any liability for the
failure to comply with, any provision of Section 16 of the Exchange Act.
This Limited Power of Attorney shall remain in full force and
effect until the undersigned is no longer required to file Forms 3, 4 or
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 signed writing delivered to the foregoing attorneys-in-
fact.
IN WITNESS WHEREOF, the undersigned has executed this Limited Power of
Attorney as of this 9th day of September 2022.
Signed and acknowledged:
/s/
Simon D. Campion
