-----BEGIN PRIVACY-ENHANCED MESSAGE----- Proc-Type: 2001,MIC-CLEAR Originator-Name: webmaster@www.sec.gov Originator-Key-Asymmetric: MFgwCgYEVQgBAQICAf8DSgAwRwJAW2sNKK9AVtBzYZmr6aGjlWyK3XmZv3dTINen TWSM7vrzLADbmYQaionwg5sDW3P6oaM5D3tdezXMm7z1T+B+twIDAQAB MIC-Info: RSA-MD5,RSA, M+ngsJLNuao+hqjc1teM/0sCTHUBr2DRyoEQpOiC27fCe8p73tbHPTQdXShj8dxD asJHxrp8MiAEOwLtx4Kf/Q== 0000950129-01-000742.txt : 20010213 0000950129-01-000742.hdr.sgml : 20010213 ACCESSION NUMBER: 0000950129-01-000742 CONFORMED SUBMISSION TYPE: 5 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20001201 FILED AS OF DATE: 20010212 SUBJECT COMPANY: COMPANY DATA: COMPANY CONFORMED NAME: PETROQUEST ENERGY INC CENTRAL INDEX KEY: 0000872248 STANDARD INDUSTRIAL CLASSIFICATION: CRUDE PETROLEUM & NATURAL GAS [1311] IRS NUMBER: 980115468 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 5 SEC ACT: SEC FILE NUMBER: 000-19020 FILM NUMBER: 1532684 BUSINESS ADDRESS: STREET 1: 400 E KALISTE SALOOM RD SUITE 3000 CITY: LAFAYETTE STATE: LA ZIP: 70508 BUSINESS PHONE: 3372327028 MAIL ADDRESS: STREET 1: 600 595 HOWE ST STREET 2: VANCOUVER BRITISH COLUMBIA CITY: CANADA V6C 2T5 STATE: A1 FORMER COMPANY: FORMER CONFORMED NAME: OPTIMA PETROLEUM CORP DATE OF NAME CHANGE: 19950726 COMPANY DATA: COMPANY CONFORMED NAME: DAIGLE RALPH J CENTRAL INDEX KEY: 0001070221 STANDARD INDUSTRIAL CLASSIFICATION: [] DIRECTOR FILING VALUES: FORM TYPE: 5 BUSINESS ADDRESS: STREET 1: P O BOX 51205 CITY: LAFAYETTE STATE: LA ZIP: 70505 BUSINESS PHONE: 3182327028 5 1 h84036e5.txt RALPH J DAIGLE FOR PETROQUEST ENERGY INC 1 -------------------------- OMB APPROVAL -------------------------- - ------ OMB Number: 3235-0362 FORM 5 Expires: December 31, 2001 - ------ Estimated average burden hours per response.... 1.0 -------------------------- UNITED STATES SECURITIES AND EXCHANGE COMMISSION WASHINGTON, DC 20549 ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP [ ] CHECK BOX IF NO LONGER SUBJECT TO SECTION 16. FORM 4 OR FORM 5 OBLIGATIONS MAY CONTINUE. SEE Filed pursuant to Section 16(a) of the Securities INSTRUCTION 1(b). Exchange Act of 1934, [ ] FORM 3 HOLDINGS Section 17(a) of the Public Utility REPORTED Holding Company Act of 1935 or Section 30(f) of [ ] FORM 4 the Investment Company Act TRANSACTIONS of 1940 REPORTED - ------------------------------------------------------------------------------------------------------------------------------------ 1. Name and Address of Reporting Person* 2. Issuer Name and Ticker or Trading Symbol 6. Relationship of Reporting Person(s) to Daigle Ralph J. PetroQuest Energy, Inc. -- PQUE Issuer (Check all applicable) - ------------------------------------------- --------------------------------------------- X Director 10% Owner (Last) (First) (Middle) 3. IRS or Social Security 4. Statement for ---- --- Number of Reporting Month/Year X Officer (give Other (specify 400 E. Kaliste Saloom Rd., Suite 3000 Person (Voluntary) 12/31/00 ---- title --- below) - ------------------------------------------- ------------------- below) (Street) -------------------- 5. If Amendment, Senior Vice Date of Original President - Exploration Lafayette Louisiana 70508 (Month/Year) ------------------------------- - ------------------------------------------- 7. Individual or Joint/Group Reporting (City) (State) (Zip) ------------------ (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. 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 (Month/ (Instr. end of Issuer's Direct Benefi- Day/ 8) Fiscal Year (D) or cial Year) ---------------------------- (Instr. 3 and 4) Indirect Owner- Amount (A) or Price (I) ship (D) (Instr. 4) (Instr. 4) - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock 12/01/00 A 33,500(1) A $3.125 2,174,500 D - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock 26,000 I By daughter - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ (1) Grant is subject to the approval of the amended and restated 1998 Incentive Plan by PetroQuest's stockholders at the 2001 annual meeting. *If the form is filed by more than one reporting person, see Instruction 4(b)(v). (Over) SEC 2270 (3-99) POTENTIAL PERSONS WHO ARE TO RESPOND TO THE COLLECTION OF INFORMATION CONTAINED IN THIS FORM ARE NOT REQUIRED TO RESPOND UNLESS THE FORM DISPLAYS A CURRENTLY VALID OMB CONTROL NUMBER.
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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) - ------------------------------------------------------------------------------------------------------------------------------------ 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) ----------------------------------- Date Expira- Amount or --------------- Exer- tion Number of (A) (D) cisable Date Title Shares - ------------------------------------------------------------------------------------------------------------------------------------ Incentive Stock Options pursuant to 1998 Incentive Common Plan $3.125 12/1/00 A 75,000 (2) 11/30/10 Stock 75,000 - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ 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) - ------------------------------------------------------------------------------------------------------ 75,000 D - ------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------ Explanation of Responses: (2) Options will vest in 1/3 installments on each of 12/01/01, 12/01/02 and 12/01/03. **Intentional misstatements or omissions of facts constitute Federal Criminal Violations. /s/ RALPH J. DAIGLE 2/7/01 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 is insufficient, see Instruction 6 for procedure. SEC 2270 (3-99)
Potential persons who are to respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB number. -----END PRIVACY-ENHANCED MESSAGE-----