------------------------------
OMB APPROVAL
------------------------------
OMB Number
Expires:
Estimated average burden
hours per response 1.0
------------------------------
U.S. SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
FORM 5
ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP
Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934,
Section 17(a) of the Public Utility Holding Company Act of 1935 or
Section 30(f) of the Investment Company Act of 1940
[_] Check box if no longer subject to Section 16. Form 4 or Form 5 obligations
may continue. See Instruction 1(b).
[_] Form 3 Holdings Reported
[_] Form 4 Transactions Reported
________________________________________________________________________________
1. Name and Address of Reporting Person*
Foran, David H.
- --------------------------------------------------------------------------------
(Last) (First) (Middle)
6801 McDivitt Drive
- --------------------------------------------------------------------------------
(Street)
Bakersfield, CA 93313
- --------------------------------------------------------------------------------
(City) (State) (Zip)
________________________________________________________________________________
2. Issuer Name and Ticker or Trading Symbol
Industrial Rubber Innovations, Inc. - IRIB
________________________________________________________________________________
3. IRS Identification Number of Reporting Person, if an Entity (Voluntary)
________________________________________________________________________________
4. Statement for Month/Year
October 31, 1999
________________________________________________________________________________
5. If Amendment, Date of Original (Month/Year)
________________________________________________________________________________
6. Relationship of Reporting Person to Issuer
(Check all applicable)
[x] Director [_] 10% Owner
[x] Officer (give title below) [_] Other (specify below)
________________________________________________________________________________
7. Individual or Joint/Group Filing
(Check applicable line)
[x] Form filed by one Reporting Person
[_] Form filed by more than one Reporting Person
________________________________________________________________________________
1
<PAGE>
================================================================================
Table I -- Non-Derivative Securities Acquired, Disposed of,
or Beneficially Owned
================================================================================
<TABLE>
<CAPTION>
5. 6.
4. Amount of Owner
Securities Acquired (A) or Securities ship
Disposed of (D) Beneficially Form: 7.
(Instr. 3, 4 and 5) Owned at End Direct Nature of
2. 3. ------------------------------ of Issuer's (D) or Indirect
1. Transaction Transaction (A) Fiscal Year Indirect Beneficial
Title of Security Date Code Amount or Price (Instr. 3 (I) Ownership
(Instr. 3) (mm/dd/yy) (Instr. 8) (D) and 4) (Instr.4) (Instr.4)
- ----------------------------------------------------------------------------------------------------------------------------------
<S> <C> <C> <C> <C> <C> <C> <C> <C>
- -----------------------------------------------------------------------------------------------------------------------------------
Common Stock, par value $0.001 04/26/99 P 110,000 A Exchange 110,000 D
Acquired in exchange for common stock
in a merger transaction
- -----------------------------------------------------------------------------------------------------------------------------------
- -----------------------------------------------------------------------------------------------------------------------------------
- -----------------------------------------------------------------------------------------------------------------------------------
- -----------------------------------------------------------------------------------------------------------------------------------
- -----------------------------------------------------------------------------------------------------------------------------------
- -----------------------------------------------------------------------------------------------------------------------------------
===================================================================================================================================
</TABLE>
* If the form is filed by more than one Reporting Person, see Instruction
4(b)(v).
Reminder: Report on a separate line for each class of securities beneficially
owned directly or indirectly.
(Over)
(Form 5-07/98)
2
<PAGE>
FORM 5 (continued)
Table II -- Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
================================================================================
<TABLE>
<CAPTION>
9. 10.
Number Owner-
of ship
2. Deriv- of
Conver- 5. 7. ative Deriv- 11.
sion Number of Title and Amount Secur- ative Nature
or Derivative 6. of Underlying 8. ities Secur- of
Exer- Securities Date Securities Price Bene- ity: In-
cise 3. Acquired (A) Exercisable and (Instr. 3 and 4) of ficially Direct direct
Price Trans- 4. or Disposed Expiration Date ---------------- Deriv- Owned (D) or Bene-
1. of action Trans- of (D) (Month/Day/Year) Amount ative at End In- ficial
Title of Deriv- Date action (Instr. 3, ---------------- or Secur- of direct Owner-
Derivative ative (Month/ Code 4 and 5) Date Expira- Number ity Year (I) ship
Security Secur- Day/ (Instr. ------------ Exer- tion of (Instr. (Instr. (Instr. (Instr.
(Instr. 3) ity Year) 8) (A) (D) cisable Date Title Shares 5) 4) 4) 4)
- -----------------------------------------------------------------------------------------------------------------------------------
<S> <C> <C> <C> <C> <C> <C> <C> <C> <C> <C> <C> <C> <C>
- -----------------------------------------------------------------------------------------------------------------------------------
Warrants $0.50 04/26/99 P 100,000 - 04/26/99 05/01/01 Common 100,000 Exchange 100,000 D
Acquired in
exchange for
common stock
fin a merger
transaction
- -----------------------------------------------------------------------------------------------------------------------------------
- -----------------------------------------------------------------------------------------------------------------------------------
- -----------------------------------------------------------------------------------------------------------------------------------
- -----------------------------------------------------------------------------------------------------------------------------------
- -----------------------------------------------------------------------------------------------------------------------------------
- -----------------------------------------------------------------------------------------------------------------------------------
===================================================================================================================================
</TABLE>
Explanation of Responses:
/s/ David H. Foran 12/14/99
- ----------------------------- ----------------------
**Signature of Reporting Person Date
** 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 provided is insufficient, see Instruction 6 for procedure.
Page 2
3
<PAGE>
Derivative Securities Codes (Except For Transactions Exempt Pursuant to
Rule 16b-3)
C--Conversion of derivative security
E--Expiration of short derivative position
H--Expiration (or cancellation) of long derivative position with value
received
O--Exercise of out-of-the-money derivative security
X--Exercise of in-the-money or at-the-money derivative security
Other Section 16(b) Exempt Transaction and Small Acquisition Codes (Except
For Rule 16b-3 Codes Above)
G--Bona fide gift
L--Small acquisition under Rule 16a-6
W--Acquisition or disposition by will or the laws of descent and
distribution
Z--Deposit into or withdrawal from voting trust
Other Transaction Codes
J--Other acquisition or disposition (describe transaction)
K--Transaction in equity swap or instrument with similar characteristics
U--Disposition pursuant to a tender of shares in a change of control
transaction
To indicate that a holding should have been reported previously on Form 3,
place a "3" in Table I, column 3 or Table II, column 4, as appropriate. Indicate
in the space provided for explanation of responses the event triggering the Form
3 filing obligation. To indicate that a transaction should have been reported
previously on Form 4, place a "4" next to the transaction code reported in Table
I, column 3 or Table II, column 4 (e.g., an open market purchase of a
non-derivative security that should have been reported previously on Form 4
should be designated as "P4"). To indicate that a transaction should have been
reported on a previous Form 5, place a "5" in Table I, column 3 or Table II,
column 4, as appropriate. In addition, the appropriate box on the front page of
the form should be checked.
FORM 3 OR FORM 4 HOLDINGS OR TRANSACTIONS
NOT PREVIOUSLY REPORTED
To indicate that a holding should have been reported previously on a Form
3, place a "3" in Table I, column 3 or Table II, column 4, as appropriate.
Indicate in the space provided for explanation of responses the event triggering
the Form 3 filing obligation. To indicate that a transaction should have been
reported previously on Form 4, place a "4" next to the transaction code reported
in Table I, column 3 or Table II, column 4 (e.g., an open market purchase of a
non-derivative security that should have been reported previously on Form 4
should be designated as "P4"). In addition, the appropriate box on the front
page of the form should be checked.
