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 _______________________________________________________________________________ 1. Name and Address of Reporting Person Nielson James E. ----------------------------------------------------- (Last) (First) (Middle) P.O. Box 2850 ----------------------------------------------------- (Street) Cody Wyoming 82414 ----------------------------------------------------- (City) (State) (Zip) _______________________________________________________________________________ 2. Issuer Name AND Ticker or Trading Symbol Synergy Technologies Corporation "OILS" _______________________________________________________________________________ 3. IRS or Social Security Number of Reporting Person (Voluntary) _______________________________________________________________________________ 4. Statement for Month/Year December 2001 _______________________________________________________________________________ 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) -------------------------------------------------- -------------------------------------------------- _______________________________________________________________________________ 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 ------------------------------------------------------------------------------------------------------------------------ 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 $0.002 326,923 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) ----------------------------------------------------------------------------------------------------------------------------------- 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 Purchase Shares * 1/17/00 1/16/05 $1.00 100,000 D ----------------------------------------------------------------------------------------------------------------------------------- Warrants to Purchase Shares 6/13/00 12/15/02 $1.00 250,000 D ----------------------------------------------------------------------------------------------------------------------------------- Options to Purchase Shares * 10/16/00 10/15/10 $1.56 100,000 D ----------------------------------------------------------------------------------------------------------------------------------- Warrants to Purchase Shares 06/20/01 06/19/03 $1.30 76,923 D ----------------------------------------------------------------------------------------------------------------------------------- Explanation of Responses: * Only 40,000 shares can be exercised in the first year; 30,000 shares can be exercised in the second year; and 70,000 shares can be exercised in the third year. /s/ James E. Nielson December 14, 2001 ---------------------------------------- -------------------- ** 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.