SEC Form 3
FORM 3 |
UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934 or Section 30(h) of the Investment Company Act of 1940 |
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1. Name and Address of Reporting Person*
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year) 11/10/2022 |
3. Issuer Name and Ticker or Trading Symbol
Permex Petroleum Corp [ OILCF ] |
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
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5. If Amendment, Date of Original Filed
(Month/Day/Year) |
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6. Individual or Joint/Group Filing (Check Applicable Line)
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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) |
Common Stock | 34,283 | D | |
Common Stock | 41,667 | I | By N.A. Energy Resources Corporation(1) |
Common Stock | 417 | I | By spouse |
Common Stock | 11,111(2) | D |
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: Direct (D) or Indirect (I) (Instr. 5) | 6. Nature of Indirect Beneficial Ownership (Instr. 5) | ||
Date Exercisable | Expiration Date | Title | Amount or Number of Shares | ||||
Employee Stock Option (right to buy) | (3) | 12/04/2027 | Common Stock | 11,250 | 21.9 | D | |
Employee Stock Option (right to buy) | (3) | 10/06/2031 | Common Stock | 12,500 | 10.51 | D | |
Common Stock Warrants (right to buy) | (2)(4) | (4) | Common Stock | 11,111 | 9.6 | D |
Explanation of Responses: |
1. The reporting person is the President and Chief Executive Officer of N.A. Energy Resources Corporation and in such capacity has the right to vote and dispose of the securities held by such entity. |
2. The reporting person was issued a secured convertible debenture in the principal amount of CAD$100,000, which debenture is convertible at the holder's option into units of the Company at US$7.20 (CAD$9.00) per unit. Each unit will be comprised of one common share of the Company and one common share purchase warrant. Each common share purchase warrant entitles the reporting person to acquire one additional common share for a period of three years at an exercise price of US$9.60 (CAD$12.00). As of the date of this report, the reporting person has not elected to convert the secured convertible debenture, and as a result, no units have been issued. |
3. The option has fully vested. |
4. The reported shares are issuable to the reporting person upon exercise of a warrant that will be issued to the reporting person upon conversion of a secured convertible debenture. See footnote (2). |
Remarks: |
Exhibit 24.1 - Power of Attorney |
/s/ Mehran Ehsan | 11/10/2022 | |
** Signature of Reporting Person | Date | |
Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | ||
* 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 is insufficient, see Instruction 6 for procedure. | ||
Persons who respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB Number. |