U.S. SECURITIES AND EXCHANGE COMMISSION
Washington, DC 20549
FORM 5
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
[_] Check box if no longer subject to Section 16. Form 4 or Form 5 obligations
may continue. See Instruction 1(b).
[_] Form 3 Holdings Reported
[X] Form 4 Transactions Reported
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1. Name and Address of Reporting Person*
GAVONI DEAN R
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(Last) (First) (Middle)
520 SW SIXTH AVENUE, SUITE 750
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(Street)
PORTLAND OR 97204-1556
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(City) (State) (Zip)
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2. Issuer Name and Ticker or Trading Symbol
NBG RADIO NETWORK, INC. "NSBD"
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3. IRS Identification Number of Reporting Person, if an Entity (Voluntary)
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4. Statement for Month/Year
NOVEMBER 30, 2001
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5. If Amendment, Date of Original (Month/Year)
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6. Relationship of Reporting Person to Issuer
(Check all applicable)
[_] Director [_] 10% Owner
[X] Officer (give title below) [_] Other (specify below)
Vice President, Operations
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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 Acquired, Disposed of,
or Beneficially Owned
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5. 6.
4. Amount of Owner-
Securities Acquired (A) or Securities ship
Disposed of (D) Beneficially Form: 7.
(Instr. 3, 4 and 5) Owned at End Direct Nature of
2. 3. ----------------------------- of Issuer's (D) or Indirect
1. Transaction Transaction (A) Fiscal Year Indirect Beneficial
Title of Security Date Code Amount or Price (Instr. 3 (I) Ownership
(Instr. 3) (mm/dd/yy) (Instr. 8) (D) and 4) (Instr.4) (Instr. 4)
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Common Stock (1) 03/05/01 P 81,539 A $1.00(2) 164,873 D
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* If the form is filed by more than one Reporting Person, see Instruction
4(b)(v).
Reminder: Report on a separate line for each class of securities beneficially
owned directly or indirectly.
(Print or Type Responses) (Over)
FORM 5 (continued)
Table II -- Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
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9. 10.
Number Owner-
of ship
2. Deriv- of
Conver- 5. 7. ative Deriv- 11.
sion Number of Title and Amount Secur- ative Nature
or Derivative 6. of Underlying 8. ities Secur- of
Exer- Securities Date Securities Price Bene- ity: In-
cise 3. Acquired (A) Exercisable and (Instr. 3 and 4) of ficially Direct direct
Price Trans- 4. or Disposed Expiration Date ---------------- Deriv- Owned (D) or Bene-
1. of action Trans- of (D) (Month/Day/Year) Amount ative at End In- ficial
Title of Deriv- Date action (Instr. 3, ---------------- or Secur- of direct Owner-
Derivative ative (Month/ Code 4 and 5) Date Expira- Number ity Year (I) ship
Security Secur- Day/ (Instr. ------------ Exer- tion of (Instr. (Instr. (Instr. (Instr.
(Instr. 3) ity Year) 8) (A) (D) cisable Date Title Shares 5) 4) 4) 4)
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Warrant to Purchase $1.50 03/05/01 P 81,539(A) 09/05/01 03/05/03 Common 81,539 $1.00(2) 81,539 D
Common Stock per share Stock
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Employee Stock $1.75 04/10/01 A 400,000 06/01/01 03/10/06 Common 400,000 400,000 D
Option to Purchase per share Stock
Common Stock
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Employee Stock $2.00 60,000 09/01/99 09/01/02 Common
Option to Purchase per share Stock 60,000 60,000 D
Common Stock
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Explanation of Responses:
(1) The shares of Common Stock may not be sold, transferred, or exchanged
before September 5,2001.
(2) This price represents the purchase price of a unit consisting of one share
of Common Stock and a warrant to purchase one share of Common Stock. Pursuant
to Instruction 4(c)(iv), the components of the units are reported separately on
Table I and Table II.
/s/DEAN R. GAVONI 3/18/02
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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.
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