Representative Name*

Type or print clearly. Representatives are required complete this form to notify the broker/dealer of outside activities performed beyond the duties of a registered representative with Brighton Securities. Activities include but are not limited to insurance sales, tax planning, accounting services, being a board member of any entity, or offering services as an independent Registered Investment Advisor.

Complete, sign, date this form and return to the Compliance Department or designated Principal. This notification must be received and approved by a designated Principal prior to the representative engaging in the activity. It is the responsibility of the representative to ensure notification is made in accordance with FINRA and Company policies and procedures.

If you have multiple outside business activities, a separate form must be completed for each activity.

Is this an update of a previously disclosed outside activity?*

Yes

No

Name of Organization

Your specific affiliation to this organization:*

Owner

Director

Partner

Employee

Agent

Officer

Consultant

Other

If owner, what is your percentage of ownership?*

Is this a publicly traded company?*

Yes

No

Describe the nature or purpose of this business (i.e. independent insurance agency, registered investment advisor that prepares financial plans):*

Describe your duties/responsibilities (i.e. determine customer needs for and sales of fixed insurance products)*

Do you have check writing authority for this business?*

Yes

No

Percentage of time devoted to this activity per week?*

Does this business involve the sale of any of the following products or services?

Accident & Health Insurance*

Yes

No

Investment Advisory Services*

Yes

No

Fixed Annuities*

Yes

No

Bank Notes*

Yes

No

Disability Insurance*

Yes

No

Mortgage Brokering*

Yes

No

Traditional Life Insurance*

Yes

No

Partnership Interest*

Promissory Notes*

Yes

No

Hedge Funds*

Yes

No

Viatical/Lifetime Settlements*

Yes

No

International Investment programs*

Yes

No

Real Estate Syndicates*

Yes

No

Offshore Products or Investments*

Yes

No

Payphone Sales*

Yes

No

ATM Sales*

Yes

No

Other*

Yes

No

If other, please explain*

Compensation*

Commission

Salary

Other

If other, please explain*

Are any of your securities clients also partners, shareholders, co-owners or associated with this outside business in any way?*

Yes

No

If Yes, please explain*

Are any of your securities clients also clients of this outside business activity?*

Yes

No

Are any of the employees, partners, co-owners or associated persons of this outside business registered with another broker-dealer?*

Yes

No

If Yes, List name of representative and broker-dealer*

Is this outside business activity in any way related to the securities industry?*

Yes

No

Do any of your duties involve raising capital or arranging credit?*

Yes

No

Have you accepted compensation from any person or entity (including a partnership, corporation, association) not covered by the above questions?*

Yes

No

The undersigned registered representative certifies that these statements are true and correct to the best of his/her knowledge. The registered representative also agrees to notify Brighton Securities immediately should any of the information change. If outside business activity is approved, the undersigned registered representative understands that their Form U4 will be updated to reflect this activity.

Registered Representative signature*

Reset

Date*

Designated Principal signature*

Reset

Date*

Compliance Documents

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