FORM 5 --------------------------
OMB APPROVAL
[ ] Check this box if no longer subject ------------
to Section 16. Form 4 or Form 5 OMB Number: 3235-0362
obligations may continue. See Expires: December 31, 2001
Instructions 1(b). Estimated average burden
hours per response...0.5
[ ] Form 3 Holdings Reported --------------------------
[ ] Form 4 Transactions Reported
UNITED STATES SECURITIES AND EXCHANGE COMMISSION
WASHINGTON, D.C. 20549
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
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1. Name and Address of Reporting Person
Haworth Cameron
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(Last) (First) (Middle)
1123 - 89 Avenue S.W.
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(Street)
Calgary Alberta Canada T2V 0W7
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(City) (State) (Zip)
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2. Issuer Name AND Ticker or Trading Symbol
Synergy Technologies Corporation
"OILS"
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3. IRS or Social Security Number of Reporting Person (Voluntary)
_______________________________________________________________________________
4. Statement for Month/Year
December 2001
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5. If Amendment, Date of Original (Month/Year)
_______________________________________________________________________________
6. Relationship of Reporting Person to Issuer
(Check all applicable)
[ ] 10% Owner
[X] Director
[ ] Officer (Give Title Below)
[ ] Other (Specify Below)
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_______________________________________________________________________________
7. Individual or Joint/Group Reporting
(Check Applicable Line)
[X] Form Filed by One Reporting Person
[ ] Form Filed by More than One Reporting Person
_______________________________________________________________________________
TABLE I--NON-DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF, OR BENEFICIALLY OWNED
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1. 2. 3. 4. 5. 6. 7.
--------------------- -------- ---------- ------------------------------ ----------- ---------- ----------
Amount of Owner-
Securities ship
Trans- Securities Acquired (A) Beneficially Form:
action or Disposed of (D) Owned at Direct Nature of
Date Trans- (Instr. 3, 4 and 5) End of (D) or Indirect
Title of (Month/ action ---------------------------- Month Indirect Beneficial
Security Day/ Code Amount (A) or Price (Instr. (I) Ownership
(Instr. 3) Year) (Instr. 8) (D) 3 and 4) (Instr. 4) (Instr. 4)
--------------------- -------- ---------- ----------- ------ --------- ----------- ---------- ----------
Common Stock $0.002 34,337 D
par value
* If the form is filed by more than one reporting person, see instruction
4(b)(v)
TABLE II--DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF, OR BENEFICIALLY OWNED
(E.G. PUTS, CALLS, WARRANTS, OPTIONS, CONVERTIBLE SECURITIES)
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1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
---------- -------- -------- -------- ---------- ------------ -------------- ------ ---------- --------- ----------
Title and Ownership
Number of Date Exer- Amount of Form of
Derivative cisable and Underlying Number of Deriv-
Securities Expiration Securities Price Derivative ative
Conver- Acquired (A) Date (Month/ (Instr. 3 of Securities Security:
sion or Trans- or Disposed Day/Year) and 4) Deriv- Benefi- Direct
Exercise action Trans- of (D) -------------- -------------- ative cially (D) or Nature of
Title of Price of Date action (Instr. 3, Date Amount Secur- Owned at Indirect Indirect
Derivative Deriv- (Month/ Code 4 and 5) Exer- Expir- or Num- ity End of (I) Beneficial
Security ative Day/ (Instr. ---------- cis- ation ber of (Instr. Month (Instr. Ownership
(Instr. 3) Security Year) 8) (A) (D) able Date Title Shares 5) (Instr. 4) 4) (Instr. 4)
---------- -------- -------- ---- --- ---- ---- ------- ----- ----- ------ ------ ---------- -------- ----------
Options to 01/05/00 01/04/05 $1.00 150,000
Purchase
Stock *
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Options to 01/05/00 01/04/10 $1.00 94,500
Purchase
Shares
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Explanation of Responses:
* 50,000 shares can be exercised in year one; 50,000 shares can be exercised in
year two; and 50,000 shares can be exercised in year three.
/s/ Cam Haworth December 17, 2001
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** 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.