UNITED STATES SECURITIES AND EXCHANGE COMMISSION
WASHINGTON, D.C. 20549
FORM 5
ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP
( ) Check box if no longer subject to Section 16.
Form 4 or Form 5 obligations may continue. See Instructions 1(b).
( ) Form 3 Holdings Reported
( ) Form 4 Transactions Reported
1. Name and Address of Reporting Person
Rasmussen, L. Carl
2351 South 2300 West
Salt Lake City, Utah 84119
USA
2. Issuer Name and Ticker or Trading Symbol
Pen Interconnect, Inc.
PENC
3. IRS or Social Security Number of Reporting Person (Voluntary)
4. Statement for Month/Year
Fiscal Year ended September 30, 1997
5. If Amendment, Date of Original (Month/Year)
6. Relationship of Reporting Person(s) to Issuer (Check all applicable)
( ) Director ( ) 10% Owner (X) Officer (give title below) ( ) Other
(specify below)
Vice President of Corporate Sales
7. Individual or Joint/Group Reporting (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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1. Title of Security |2. |3. |4.Securities Acquired (A) |5.Amount of |6.Dir |7.Nature of Indirect |
|Transaction| or Disposed of (D) | Securities |ect | Beneficial Ownership |
|Date |Code| | Beneficially |(D)or | |
| | | | A/| | Owned at |Indir | |
| | | Amount | D | Price | End of Year |ect(I)| |
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Table II -- Derivative Securitites Acquired, Disposed of, or Beneficially Owned |
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1.Title of Derivative |2.Con |3. |4. |5.Number of De |6.Date Exer |7.Title and Amount|8.Price|9.Number |10.|11.Nature of|
Security |version |Transaction| rivative Secu |cisable and | of Underlying |of Deri|of Deriva |Dir|Indirect |
|or Exer |Date |Code| rities Acqui |Expiration | Securities |vative |tive |ect|Beneficial |
|cise Pr | | | red(A) or Dis |Date(Month/ | |Secu |Securities|(D)|Ownership |
|ice of | | | posed of(D) |Day/Year) | |rity |Benefi |or | |
|Deriva | | | |Date |Expir | | |ficially |Ind| |
|tive | | | | A/|Exer- |ation |Title and Number | |Owned at |ire| |
|Secu | | | | D |cisa- |Date |of Shares | |End of |ct | |
|rity | | | Amount | |ble | | | |Year |(I)| |
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Employee Stock Option $1.38 022297 A 25,000 - 022297 022207 Common Stock 75,000 54,500(1) D
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Explanation of Responses:
(1) Inclueds option granted in September, 1995 as earlier reported on Form 3
filed with the Commission.
SIGNATURE OF REPORTING PERSON
/s/ L. Carl Rasmussen
DATE
November 13, 1997
