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FORM 5 OMB Number: 3235-0362
- ------ Expires: April 30, 1997
Estimated average burden
hours per response........1.0
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/ / Check box if no U.S. SECURITIES AND EXCHANGE COMMISSION
longer subject to WASHINGTON, DC 20549
Section 16. Form
4 or Form 5 ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP
obligations may
continue. See Filed pursuant to Section 16(a) of the Securities
Instruction 1(b) Exchange Act of 1934,
/X/ Form 3 Holdings Section 17(a) of the Public Utility
Reported Holding Company Act of 1935 or Section 30(f) of
/X/ Form 4 the Investment Company Act
Transactions of 1940
Reported
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<S> <C> <C> <C> <C> <C> <C>
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1. Name and Address of Reporting Person* 2. Issuer Name and Ticker or Trading Symbol 6. Relationship of Reporting Person to
Cornwell Jerry PAN Environmental Corporation ("PANE") Issuer (Check all applicable)
- ------------------------------------------- ---------------------------------------------- X Director X 10% Owner
(Last) (First) (Middle) 3. IRS or Social Security 4. Statement for ---- ---
Number of Reporting Month/Year X Officer (give Other (specify
- ------------------------------------------- Person (Voluntary) 1997 ---- title --- below)
(Street) ------------------- below)
N/A 5. If Amendment, President and
- ------------------------------------------- Date of Original Chief Executive Officer
(City) (State) (Zip) (Month/Year) -------------------------------
N/A
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TABLE 1 -- NON-DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF, OR BENEFICIALLY OWNED
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1. Title of Security 2. Trans- 3. Transac- 4. Securities Acquired (A) 5. Amount of Se- 6. Owner- 7. Nature
(Instr. 3) action tion or Disposed of (D) curities Benefi- ship of In-
Date Code (Instr. 3, 4 and 5) cially Owned at Form: direct
(Instr. 8) End of Issuer's Direct Benefi-
(Month/ Fiscal Year (D) or cial
Day/ ---------------------------- (Instr. 3 and 4) Indirect Owner-
Year) Amount (A) or Price (I) ship
(D) (Instr. 4) (Instr.
4)
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Common Stock 1/2/1996 120,709 A * D
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Common Stock 1/2/1996 116,000 A $58,000 D
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Common Stock 1/2/1996 168,436 A $84,218 D
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Common Stock 1/2/1996 45,772 A * I (1)
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Common Stock 1/2/1996 64,179 A * I (1)
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Common Stock 1/2/1996 103,401 A * I (1)
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Common Stock 1/2/1996 110,013 A * I (1)
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Common Stock 1/2/1996 17,503 A * I (1)
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Common Stock 1/2/1996 155,600 A $77,800 I (2)
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Common Stock 3/2/1997 130,000 A $ 8,000 I (2)
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Common Stock 3/2/1997 100,000 A $25,000 $1,131,613 I (2)
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. (Over)
(Print or Type Responses) SEC 2270 (3/91)
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FORM 5 (CONTINUED) TABLE II -- DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF, OR BENEFICIALLY OWNED
(E.G., PUTS, CALLS, WARRANTS, OPTIONS, CONVERTIBLE SECURITIES)
<S> <C> <C> <C> <C> <C> <C> <C>
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1. Title of Derivative 2. Conver- 3. Trans- 4. Trans- 5. Number of 6. Date Exer- 7. Title and Amount 8. Price
Security sion or action action Derivative cisable and of Underlying of
(Instr. 3) Exercise Date Code Securities Ac- Expiration Securities Deriv-
Price of (Month/ (Instr. 8) quired (A) or Date (Instr. 3 and 4) ative
Deriv- Day/ Disposed of (D) (Month/Day/ Secur-
ative Year) (Instr. 3, 4, Year) ity
Security and 5) (Instr. 5)
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Date Expira- Amount or
--------------- Exer- tion Title Number of
(A) (D) cisable Date Shares
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D 0**
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<C> <C> <C> <C>
1. Title of Derivative 9. Number of 10. Ownership 11. Nature of
Security Derivative of Derivative Indirect
(Instr. 3) Securities Security: Beneficial
Beneficially Direct (D) Ownership
Owned at End or Indirect (I) (Instr. 4)
of Year (Instr. 4)
(Instr. 4)
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Explanation of Responses:
* Issued pursuant to the December 7, 1995 settlement agreement in lieu of stock options granted and
cancelled under the Company's 1994 Stock Option Plan.
** Mr. Cornwell had a right to acquire beneficial ownership of 300,000 shares of common stock contingent
upon receipt by PAN Environmental Corporation of equity financing of at least $4,000,000. This
financing never took place.
(1) Mr. Cornwell is President, CFO and 100% owner of XXX Enterprises Corp which holds the shares in
trust for certain participants, which shares were issued pursuant to the Dec. 7, 1995 settlement
agreement in lieu of stock option granted and cancelled under the Company's 1994 Stock Option Pension
Plan.
(2) Mr. Cornwell is a managing member and 50% owner of TCKTS, L.L.C. dba Bristol Media Ltd. owner of the
shares. Bristol Media Ltd holds the 155,600 shares and the 130,000 shares in trust for debt
settlement and the 100,000 shares for $25,000 consideration consisting of cash paid on behalf of
PAN for debts and services rendered to PAN.
**Intentional misstatements or omissions of facts constitute Federal Criminal Violations.
See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). ------------------------------- -------
**Signature of Reporting Person Date
Note. File three copies of this form, one of which must be manually signed. Page 2
If space provided is insufficient, see Instruction 6 for procedure. SEC 2270 (3/91)
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