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- ------ OMB APPROVAL
FORM 5 ---------------------------
- ------ OMB Number: 3235-0362
Expires: September 30, 1998
Estimated average burden
hours per response......1.0
[ ] 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,
[ ] Form 3 Holdings Section 17(a) of the Public Utility
Reported Holding Company Act of 1935 or Section 30(f) of
[ ] 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
ROAKE STEPHEN M IRA Issuer (Check all applicable)
- ------------------------------------------- PAN INTERNATIONAL GAMING, INC. Director X 10% Owner
(Last) (First) (Middle) (FORMERLY PAN ENVIRONMENTAL CORP) ---- ---
10650 RIVIERA PL NW "PANE" Officer (give Other (specify
- ------------------------------------------- ---- title --- below)
(Street) --------------------------------------------- below)
SEATTLE, WA 98125 3. IRS or Social Security 4. Statement for
- ------------------------------------------- Number of Reporting Month/Year -------------------------------
(City) (State) (Zip) Person (Voluntary) 1998
------------------ 7. Individual or Joint/Group Filing
N/A 5. If Amendment, (Check applicable line)
Date of Original X Form Filed by one
(Month/Year) ---- Reporting Person
N/A Form Filed by more than
------------------ ---- one Reporting Person
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TABLE 1 -- NON-DERIVATATIVE 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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12/31
COMMON STOCK 1998 P 189,804 A $94,902 189,804
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JAN
COMMON STOCK 1994 - - - - NO ACTIVITY - - - - 166,666
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12/11
COMMON STOCK 1997 - - - - NO ACTIVITY - - - - 60,000
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TOTAL 416,470
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*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)
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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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<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:
**Intentional misstatements or omissions of facts constitute Federal Criminal Violations. /s/ Stephen M. Roake 4/29/99
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 in this form are not required to respond Page 2
unless the form displays a currently valid OMB number. SEC 2270 (7-97)
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