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FORM 3
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, DC 20549 INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES 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* Warrack Kelly Larry (Last) (First) (Middle) 335 - 25 Street S.E. (Street) Calgary Alberta T2A 7H8 (City) (Province) (Postal Code) |
2. Date of Event Requiring Statement (Month/Day/Year) August 1, 2001 |
4. Issuer Name and Ticker or Trading Symbol Synergy Technologies Corporation "OILS" |
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3. I.R.S. Identification Number of Reporting Person, If an entity (Voluntary) |
5. Relationship of Reporting Person(s) to Issuer (Check all Applicable) Director ___ 10% Owner _X__ Officer ___ Other (Give Title Below) (Specify Below) Secretary-Treasurer __________________ |
6. If Amendment, Date of Original (Month/Day/Year) |
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7. Individual or Joint/Group Filing (Check Applicable Line) X Form Filed by One Reporting Person ___ Form Filed by More than One Reporting Person |
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TABLE I - NON-DERIVATIVE SECURITIES BENEFICIALLY OWNED |
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1. Title of Security (Instr. 4) |
2. Amount of Securities Beneficially Owned (Instr. 4) |
3. Ownership form: Direct (D) or Indirect (I) (Instr. 5) |
4. Nature of Indirect Beneficial Ownership (Instr. 5) |
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Common Stock |
9,500 |
D |
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Common Stock |
12,500 |
I |
Held in Wife's Name |
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TABLE II - DERIVATIVE SECURITIES BENEFICIALLY OWNED (e.g., puts calls warrants options, convertible securities) |
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1. Title of Derivative Security (Instr. 4) |
2. Date Exercisable and Expiration Date (Month/Day/Year) |
3. Title and Amount of Securities Underlying Derivative Security (Instr. 4) |
4. Conversion or Exercise Price of Derivative Security |
5. Ownership Form of Derivative Securities: Direct (D) or Indirect (I) (Instr. 5) |
6. Nature of Indirect Beneficial Ownership (Instr. 5) |
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Date Exercisable |
Expiration Date |
Title |
Amount or Number of Shares |
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Options |
01/00 |
01/05 |
Common Stock |
45,000 |
$1.00 |
D |
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly Explanation of Responses:
*If the form is filed by more than one reporting person, see Instruction 5(b)(v). ** 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. |
/s/Kelly Warrack **Signature of Reporting Person |
August 24, 2001 Date |
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