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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 OMB APPROVAL
Section 16. Form ------------------------------
4 or Form 5 ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OMB Number: 3235-0362
obligations may Expires: September 30, 1998
continue. See Filed pursuant to Section 16(a) of the Securities Estimated average burden
Instruction 1(b) Exchange Act of 1934, hours per response.........1.0
[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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1. Name and Address of Reporting Person* 2. Issuer Name and Ticker or Trading Symbol 6. Relationship of Reporting Person to
Cornwell Jerry Pan International Gaming, Inc. Issuer (Check all applicable)
- ------------------------------------------- (Formerly Pan Environmental Corporation) X Director X 10% Owner
(Last) (First) (Middle) "PANE" ---- ---
2707 Dabob Road X Officer (give Other (specify
- ------------------------------------------- ---------------------------------------------- ---- title --- below)
(Street) 3. IRS or Social Security 4. Statement for below)
Quilcene, WA 98376 Number of Reporting Month/Year President & Chief Executive
- ------------------------------------------- Person (Voluntary) 1999 Officer
(City) (State) (Zip) N/A ------------------- -------------------------------
-------------------------- 5. If Amendment, 7. Individual or Joint/Group Filing
Date of Original (Check applicable line)
(Month/Year) X Form Filed by one
N/A ---- 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 1/20/98 -------- No Activity --------- 39,334 D
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Common Stock 1/02/96 -------- No Activity --------- 168,436 D
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Common Stock 1/02/96 -------- No Activity --------- 64,179 I (1)
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Common Stock 1/02/96 -------- No Activity --------- 103,401 I (1)
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Common Stock 1/02/96 -------- No Activity --------- 110,013 I (1)
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Common Stock 1/02/96 -------- No Activity --------- 17,503 I (1)
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Common Stock 1/02/96 -------- No Activity --------- 155,600 I (2)
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Common Stock 1/02/96 -------- No Activity --------- 61,000 I (2)
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Common Stock 10/01/98 -------- No Activity --------- *120,000 D
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Various
Common Stock 1998 -------- No Activity --------- 21.000 D
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Sept **
Common Stock 1999 J 10.00 D 0 21.653 I (2)
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Various
Common Stock 1998 -------- No Activity --------- 57,200 I (2)
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Common Stock 05/22/98 -------- No Activity --------- 545,000 I (2)
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Various
Common Stock 1999 S 79,694 D $38,875.00 *66,306 I (2)
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Various
Common Stock 1999 P 61.450 A $68,392.62 61,450 D (2)
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Various
Common Stock 1999 P 10.500 A $6,015.00 10.500 I
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*S-8 Registered Offering in Lieu of Wages
**Partnership distribution to Ex-Partner Jerry M. Durkis and Valhalla Marketing LLC
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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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#1 Mr. Cornwell is President, CEO and 100% Owner of xxx Enterprises Corp. which holds shares in trust for certain participants
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for whom shares were issued Pursuant to the Dec. 7, 1995 settlement agreement in lieu of stock options granted and cancelled
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under the Company's 1994 Stock Option Plan.
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#2 Mr. Cornwell is a Managing Member and 50% Owner of TCKTS, LLC DBA Bristol Media LTD and Yalhalla Financial Group, LLC and
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President, CEO and 100% Owner of XXX Enterprises Corp.
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<C> <C> <C>
9. Number of 10. Ownership 11. Nature of
Derivative of Derivative Indirect
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/ Jerry Cornwell 3/15/00
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. (8/96)
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