<PAGE> 1
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FORM 5
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/ / Check box if no U.S. SECURITIES AND EXCHANGE COMMISSION
longer subject to WASHINGTON, DC 20549
Section 14. 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
<TABLE>
<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
Pan International Gaming, Inc. Issuer (Check all applicable)
(Formerly Pan Environmental Corp) X Director X 10% Owner
CORNWELL JERRY "PANE" ---- ---
- ------------------------------------------- ---------------------------------------------- X Officer (give Other (specify
(Last) (First) (Middle) 3. IRS or Social Security 4. Statement for ---- title --- below)
14424 SE 78th Way Number of Reporting Month/Year below)
- ------------------------------------------- Person (Voluntary) President and Chief Executive
(Street) N/A 1998 Officer
Newcastle, WA 98059 ------------------- -------------------------------
- ------------------------------------------- 5. If Amendment,
(City) (State) (Zip) Date of Original 7. Individual or Joint/Group Filing
(Month/Year) (Check applicable line)
N/A X Form Filed by one
------------------ ---- Reporting Person
Form Filed by more than
---- one Reporting Person
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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 6/8/1998 J(A) 120,709 D 0 0 D
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Common Stock 1/20/1998 G 76,666 D 0 39,334 D
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Common Stock 1/2/1996 No Activity 168,436 D
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Common Stock 2/5/1998 J(B) 45,772 D $11,250.00 0 I (2)
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Common Stock 1/2/1996 No Activity 64,179 I (1)
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Common Stock 1/2/1996 No Activity 103,401 I (1)
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Common Stock 1/2/1996 No Activity 110,013 I (1)
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Common Stock 1/2/1996 No Activity 17,503 I (1)
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Common Stock 1/2/1996 No Activity 155,600 I (2)
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$0.50 SH
Common Stock 3/26/1997 J(C) 69,000 D $34,500 61,000 I (2)
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Common Stock 1/19/1998 J(D) 100,000 D 0 0 I (2)
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$1.00 SH
Common Stock 10/1/1998 J* 120,000 A $120,000 120,000 D
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Common Stock Various 1998 P 29,500 A $41,722 21,000 D
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Common Stock Various 1998 S 8,500 D $8,200 0 D
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Common Stock 1/1/1998 31,653 A 0 31,653 I (2)
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Common Stock Various 1998 P 57,200 A $63,203 57,200 I (2)
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Common Stock 5/22/1998 J(E) 625,000 A & D 0 545,000 I (2)
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Common Stock 10/1/1998 J** 146,000 A $146,000 146,000 I (2)
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* S-8 Registered Offering in lieu of wages
** S-8 Registered Offering in lieu of consulting fees
*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)
(Print or Type Responses) (8/96)
</TABLE>
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<TABLE>
<CAPTION>
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)
-----------------------------------
Date Expira- Amount or
--------------- Exer- tion Title Number of
(A) (D) cisable Date Shares
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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:
#1) MR. CORNWELL IS PRESIDENT, CEO AND 100% OWNER OF XXX ENTERPRISES CORP,
WHICH HOLDS THE SHARES IN TRUST FOR CERTAIN PARTICIPANTS FOR WHOM SHARES WERE
ISSUED PURSUANT TO THE DEC. 7, 1995 SETTLEMENT AGREEMENT IN LIEU OF STOCK OPTIONS
UNDER THE COMPANY'S 1994 STOCK OPTION PLAN.
#2) MR. CORNWELL IS A MANAGING MEMBER AND 50% OWNER TO TCKTS LLC DBA BRISTOL
MEDIA LTD AND VALHALLA FINANCIAL GROUP, LLC AND PRESIDENT, CEO AND 100% OWNER
OF XXX ENTERPRISES CORP. MR. CORNWELL ACQUIRED HIS 50% INTEREST IN VALHALLA
FINANCIAL GROUP LLC ON 1-1-98.
**Intentional misstatements or omissions of facts constitute Federal Criminal Violations. /s/ JERRY CORNWELL 4/28/99
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.
If space provided is insufficient, see Instruction 6 for procedure.
Potential persons who are to respond to the collection of information contained in this form are not required to respond Page 2
unless the form displays a currently valid OMB number. (8/96)
</TABLE>
<PAGE> 3
3(J)(A)
JERRY CORNWELL
ANALYSIS OF CERTIFICATE #2652
FOR 120,709 SHARES DISPOSED OF
<TABLE>
<CAPTION>
Price
Per Total
Date Description Shares Share Price
- ---- ----------- ------ ----- -----
<S> <C> <C> <C> <C>
06/08/98 Tom Fitzhugh - Nominee Distribution 4,335 -0- -0-
J. Schweigert - Nominee Distribution 6,000 -0- -0-
M. Hockstadt - Nominee Distribution 1,000 -0- -0-
A. Kelly - Nominee Distribution 1,000 -0- -0-
C. Etheridge - Nominee Distribution 1,000 -0- -0-
S. McCowan - Nominee Distribution 15,000 -0- -0-
R. Fitzhugh - Nominee Distribution 42,374 -0- -0-
R. Fitzhugh - Nominee Distrubiton 50,000 -0- -0-
------- ---
Total 120,709
</TABLE>
<PAGE> 4
3(J)(B)
XXX ENTERPRISES CORP.
ANALYSIS OF CERTIFICATE #2661
FOR 45,772 SHARES DISPOSED OF
<TABLE>
<CAPTION>
Price
Per Total
Date Description Shares Share Price
- ---- ----------- ------ ----- -----
<S> <C> <C> <C> <C>
02/05/98 Jones Law Group ) Given on 6,000 $.50 $ 3,000.00
Stephen Tollefsen ) on behalf 4,000 .50 2,000.00
Catherine E. Dixon ) of PAN 12,500 .50 6,250.00
02/25/98 Edward R. Jones - Gift 499 -0- -0-
03/06/98 D. Anderson - Nominee Distribution 2,333 -0- -0-
David Jack - Nominee Distribution 3,500 -0- -0-
D. Ekblad - Nominee Distribution 1,167 -0- -0-
Ray Barner - Nominee Distribution 7,886 -0- -0-
R. Fitzhugh - Nominee Distribution 7,887 -0- -0-
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Total 45,772 $11,250.00
</TABLE>
<PAGE> 5
3(J)(C)
TCKTS, L.L.C. DBA BRISTOL MEDIA, LTD.
ANALYSIS OF CERTIFICATE #2674
FOR 130,000 SHARES DISPOSED OF
<TABLE>
<CAPTION>
Price
Per Total
Date Description Shares Share Price
- ---- ----------- ------ ----- -----
<S> <C> <C> <C> <C>
06/23/98 Bonnie Myers - Private Sale 40,000 $.50 $20,000.00
Lois L. Gardiner - Private Sale 4,000 .50 2,000.00
John Hatfield - Private Sale 4,000 .50 2,000.00
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Subtotal 69,000 $34,500.00
Shares retained 12/31/98 61,000
Total 130,000
</TABLE>
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3(J)(D)
TCKTS, L.L.C. DBA BRISTOL MEDIA, LTD.
ANALYSIS OF CERTIFICATE #2671
FOR 100,000 SHARES DISPOSED OF
<TABLE>
<CAPTION>
Price
Per Total
Date Description Shares Share Price
- ---- ----------- ------ ----- -----
<S> <C> <C> <C> <C>
01/19/98 Gene Ekblad - Finders Fee 50,000 -0- -0-
Gene Ekblad - Finders Fee 1,000 -0- -0-
Casey Jones Corp. - Bonus 9,300 -0- -0-
Donald W. Jones - Bonus 7,366 -0- -0-
Tom Fitzhugh - Finders Fee 26,666 -0- -0-
Ed Jones - Gift 5,668 -0- -0-
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Total 100,000 -0-
</TABLE>
<PAGE> 7
3(J)(E)
TCKTS, L.L.C. DBA BRISTOL MEDIA, LTD.
ANALYSIS OF CERTIFICATE #2753
FOR 625,000 SHARES DISPOSED OF
<TABLE>
<CAPTION>
Price
Per Total
Date Description Shares Share Price
- ---- ----------- ------ ----- -----
<S> <C> <C> <C> <C>
05/22/98 Randy Fitzhugh - Consulting
service incident to acquisition
of Whitfield 80,000 -0- -0-
-------- ---
Subtotal 80,000 -0-
Stock retained as of 12/31/98 545,000
Subtotal 625,000
Stock Issued Directly
Whitfield Group, Ltd. ) Consulting services 10,000
J. Paul Christensen ) incident to acquisition 10,000
Kistler Mortgage Corp. ) of Whitfield 155,000
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Subtotal 175,000
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Total 800,000
</TABLE>
