Outside Business Activity Disclosure - Veritas Independent Partners (Page 2 of 2) in pdf

5. If your degree of ownership is less than 100% are any other owners Veritas Clients or affiliates? If yes

explain

6. Your title/position____________________________________________________________________

7. Date started/or anticipated start_____________________________________________________________

8. Duties_________________________________________________________________________________

_________________________________________________________________________________________

9. Hours spent on activity___________________________________________________________________

10. Is this business disclosed on your U4? _______________________________________________________

11. Do you have a financial interest in the business? If yes, Explain: __________________________________

_________________________________________________________________________________________

12. How are you compensated by this business___________________________________________________

13. Estimated annual income__________________________________________________________________

14. Does the entity identified in Item 2 maintain a securities account with Veritas ___________________

15. Have you ever or do you intend to recommend an investment in, including the purchase or sale of

securities, of the entity identified above? _______________________________________________

16. Are you aware of any potential conflict of interest your involvement in the activity may pose? __________

Explain________________________________________________________________________________

COMPLETE THE FOLLOWING FOR INSURANCE BUSINESS ONLY:

a. Lines of Insurance_____________________________________________________________________

b. Companies with whom you do business____________________________________________________

___________________________________________________________________________________

c. States in which you are licensed: _________________________________________________________

d. Percentage of business_________________________________________________________________

Are you associated with an insurance marketing wholesaler? If so, whom? ______________________________

Signature of Representative

Date

For Internal Use Only:

Received and reviewed:

Managing Supervisor/Principal

Date

Outside Business Activity Disclosure - Veritas Independent Partners Page 2