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 --------------------------
[X] 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
Cernovitch Marc
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(Last) (First) (Middle)
c/o 335 - 25 Street S.E.
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(Street)
Calgary Alberta Canada T2A 7H8
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(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
[ ] Director
[X] Officer (Give Title Below)
[ ] Other (Specify Below)
Vice President
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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
Date Trans- (Instr. 3, 4 and 5) End of (D) or
Title of (Month/ action ---------------------------- Month Indirect Nature of
Security Day/ Code Amount (A) or Price (Instr. (I) Indirect Beneficial
(Instr. 3) Year) (Instr. 8) (D) 3 and 4) (Instr. 4) Ownership (Instr. 4)
--------------------- -------- ---------- ----------- ------ --------- ----------- ---------- ----------------------
Common Stock 247,936 D
$0.002 June 30, 2001 74,400 A $0.65 549,600 I These shares are owned
by CMJ Consulting of
which Mr.Cernovitch is
the sole owner,
officer and director
* 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 01/04/10 $1.00 235,000 D
Purchase
Shares
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Warrants to 02/18/01 02/17/03 $1.00 470,000 I These shares
Purchase 02/08/01 04/07/03 $1.00 124,686 I are owned by
Shares 06/30/01 06/29/03 $1.30 74,400 I CMJ
Consulting
which Mr.
Cernovitch
is the sole
owner,
officer and
director
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Explanation of Responses:
/s/ Marc Cernovitch December 14, 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.