Prime Capital Services, Inc.

Outside Business Activity Disclosure Request Form

(A separate form must be completed for each proposed outsideactivity)

Check the appropriate category below:

_____ Prospective RR/New Hire _____ Established RR _____ Registered Sales Assistant

_____ Associated Person _____ Home Office Employee

Section I

I attest that I do not engage or plan to engage in any Outside Business Activities. ______

Initial-skip to Signature

Is this a resubmission of a previously disclosed OBA? ___ yes ___ no

Name of the OBA Applicant ______

PCS Office Location______OSJ Mgr Name ______

Name of the Proposed Outside Business Activity ______

Business Address of the OBA ______

Will this OBA be conducted under a DBA “doing business as” name? ___ yes ___ no

What is the DBA name? ______DBA approved? ___ yes ___ no

Has this activity previously been disclosed to FINRA on Form U-4? ___ yes ___ no

Section II

What is the applicant’s role/title in the OBA? ______

(Owner, employee, volunteer, officer, etc.)

Method of Compensation? ______

(Wages, commissions, stock options, fees, rental income, etc.)

Weekly hours spent on the activity: ______Anticipated Weekly Compensation: ______

Check the item applicable to this outside business activity (OBA):

____ Owner of rental property____ Charitable/Non-profit Org

In what capacity?______

____ Sports Coach/Referee____ Multi-level marketing

Through what company(s)?______

____ P & C Insurance Sales____ Insurance Broker (check products sold)

____ Whole Life ____ Term Life ____ Fixed Annuities

____ Group Annuities ____ Health ____ Dis. Income

____ Teacher____ Equity Indexed Annuities

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____ Real estate (commercial or residential) ____ as R/E broker ____ for personal investment

____ Mortgage Broker _____ Reverse Mortgages ____ Notary Public ____ Other (non-financial)

____ Director/Officer of a Company: ____ controlling shareholder ____ public co. ____ private co.

Type of Company: ______Tax Prep (thru GC) ______

____ Attorney (specify legal services provided)____ Consulting (specify)______

____ Outside RIA activities. RIA Entity offering products/services? ______

____ Other financial services (specify) ______

____ Candidate for Political Office –In what Jurisdiction?______

Please provide a comprehensive description of the proposed outside business activity. This information should be sufficiently detailed to permit your OSJ Manager and any relevant Home Office personnel the opportunity to make an informed decision in regard to whether or not the activity will be permitted. Any descriptive supporting documentation that could aid in this review should be submitted to your OSJ Manager and subsequently to PCS Compliance. Please keep in mind that this is your opportunity to explain your proposed activity and to justify why you should be permitted to engage in it. If the firm does not have sufficient detail upon which to base an informed review, the activity will be rejected. (If additional space is needed, please attach another sheet).

I attest that the information provided above represents a true and accurate disclosure of the proposed outside activity described herein. I will abide by PCS’ final determination as to my participation in this activity.

______

RR SignatureDate OSJ Mgr Date

______Compliance Approval Date Compliance Rejection Date

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