Funding Network Registration

1
What type of funding are you looking to obtain?* This field is required.
Personal Funding
Business Funding
Auto Funding
Mortgage Funding
Debt Consolidation
Investment Funding
2
Full name* This field is required.
First Name
Last Name
3
Birthday* This field is required.
4
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Type of residence* This field is required.
I own my home
I'm renting
Other
6
How long have you lived in your given address?* This field is required.
0-1 Year
1-2 Years
3-4 Years
5+ Years
7
Email* This field is required.
example@example.com
8
Phone number* This field is required.
Area Code
Phone Number
9
Estimate your credit* This field is required.
Super Prime 760 - 850 (Excellent)
Prime 701 - 759 (Good)
Sub Prime 640 - 700 (Fair)
Below Sub Prime 0 - 639 (Poor)
10
Credit report fundamentals* This field is required.
Please Select
Please Select
0
1
2
3
4 or more
I don't know
How many positive revolving accounts do you have on your credit report? Example: Credit cards, store cards, lines of credit, etc.
Please Select
Please Select
0
1
2
3
4 or more
I don't know
How many positive installment accounts do you have on your credit report? Example: Auto loans, Mortgage loans, Student loans, etc
Please Select
Please Select
0
1 to 3
3 to 5
5 or more
I don't know
How many Inquiries do you have on your credit report within the last 24 months?
Please Select
Please Select
0
1
2
3
4 or more
I don't know
How many accounts are reporting negatively on your credit report? Example: Late pays, collections, repossessions, bankruptcy,etc.
11
Is there a Security Freeze on your credit reports?Call the TransUnion, Equifax, and Experian and have them REMOVE the security freeze for 30 days!
There is no security freeze on my reports
There is a security freeze and I will call the credit agencies to have them removed after I complete this form today
There is a security freeze and I am a Breitman Capital member and I need Breitman to remove them for me asap
I don't know if there is a security freeze but I will call the credit agencies and check right after I complete this form today
12
What's your employment status* This field is required.
Full Time
Part Time
Self Employed
Unemployed
Retired
Gov't Assistance
Other
13
Your annual pre-tax income* This field is required.
14
Social security number?* This field is required.
15
Front of ID/Drivers license* This field is required.
Drag and drop files here
Select files to upload
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16
Front of Social security card* This field is required.
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Select files to upload
Max. file size: 10.6MB
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17
Where do you check your Credit?* This field is required.(Identity IQ, Privacy Guard, Experian, MyFico, etc.......)
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18
Username for the Credit Monitoring Site* This field is required.Username and/or email login. Please make sure to verify your username/email before entering to prevent service delays.
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Ok
19
Password for the Credit Monitoring Site* This field is required.Please make sure to verify your password before entering to prevent service delays.
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20
Do you have any credit freezes or fraud alerts on your credit file?* This field is required.If so, what exact day were they added and what is the pin code because we have to remove them before going through your funding session.
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21
Are you or your immediate family members currently or previously a member of the military?* This field is required.This can only be you, your spouse, mom, father, brother, or sister.
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22
Do you want to add a co-borrower?* This field is required.
Please Select
Please Select
Yes
No
Your Co-Borrower's Annual Pre-Tax Income (Optional)
23
Company name* This field is required.
24
Company phone number* This field is required.
25
Business email address* This field is required.
example@example.com
26
Industry* This field is required.
27
Business website address* This field is required.
28
Business description* This field is required.
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29
EIN certificate* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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30
Articles of organization* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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31
Business license (If Available Not Required)
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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32
Business marketing material (If Available Not Required)
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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33
Years in business* This field is required.
0-1 Year
1-2 Years
3-4 Years
5+ Years
34
Gross monthly revenue* This field is required.
35
Most recent business bank statement
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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36
Second most recent business bank statement
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Select files to upload
Max. file size: 10.6MB
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37
Third most recent business bank statement
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Select files to upload
Max. file size: 10.6MB
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38
What type of Personal funding do you want?* This field is required.Choose one or more
Credit Cards
Store Cards
Line of Credit
Personal Loans
Other
39
What type of Business funding do you want?* This field is required.Choose one or more
Credit Cards
Store Cards
Line of Credit
Business Loans
Other
40
Funding amount requested* This field is required.
41
Reason for funding* This field is required.
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42
What make and model car do you want to purchase?* This field is required.List information and be detailed. You may send links to websites to show us the exact vehicle.
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43
What is the address of the house that you want to purchase?* This field is required.List all of the details. You may share direct internet links too.
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44
What kind of investment opportunity do you have for the requested funds? Tell us why this project is valuable.* This field is required.
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45
Executive Summary or Electronic Press Kit
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Select files to upload
Max. file size: 10.6MB
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46
Financial Projections
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Select files to upload
Max. file size: 10.6MB
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47
How much debt do you have to consolidate?* This field is required.Give us the details. What accounts and the debt amount.
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48
Upload a Business Plan
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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49
Most recent pay stub
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Select files to upload
Max. file size: 10.6MB
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50
Second most recent pay stub
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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51
Third most recent pay stub
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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52
Most recent tax return
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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53
Second most recent tax return
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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54
Bank name* This field is required.
First Name
Last Name
55
Type of bank account* This field is required.
Checking
Savings
Business Checking
Business Savings
Other
56
10 points aka "percent" of all future funding amounts from the lenders/creditors/investors procured or brokered by Breitman Capital, LLC. (Including all credit cards, loans, and lines of credit.) This agreed brokering fee must be paid via credit card, ACH payment, wire, zelle, venmo, cashier's check, or money order within 24 hours of receiving the funding.) Failure to pay the above agreed terms will result in your account being charged via ACH payment from the account listed above. If payment does not clear and is still unpaid, this will result in your account being in default and will be sent to our collections department. And we will be forced to pursue you and/or your company to the fullest extent of the law. By selecting "Yes" you agree and fully acknowledge to be charged 15 points aka "percent" of your funding amount by via ACH payment from the account listed above and you will not dispute or chargeback this transaction.* This field is required.
YES
57
I authorize prospective Credit Grantors/Lending/Leasing Companies to obtain personal and credit information about me from my employer and credit bureau, or credit reporting agency, any person who has or may have any financial dealing with me, or from any references I have provided. This information, as well as that provided by me in the application, will be referred to in connection with this lease and any other relationships we may establish from time to time. Any personal and credit information obtained may be disclosed from time to time to other lenders, credit bureaus or other credit reporting agencies.* This field is required.
YES
58
I hereby agree that the information given is true, accurate and complete as of the date of this application submission.* This field is required.
YES
59
Full Signature* This field is required.
Clear
60
Are you ready to pay the $50 admission for the funding session today?
YESNO
61
Any special notes or comments you wish to add?
62
Finalizing Order Instructions

Follow these instructions thoroughly for fast order processing.

Step 1: Check your email for the Service Agreement.
Step 2: Review the service agreement and sign via DocuSign.
Step 3: Check your email for the Invoice.
Step 4: Review the Invoice and complete payment to Escrow.
Step 5: Check your email for Escrow and Breitman Capital emails to complete the order.
Step 6: Check your email for the purchase receipt from both Escrow and Breitman Capital.
Step 7: Be very attentive to your email to complete the Escrow transaction steps.

Our secure order processing with Escrow may take 1 to 2 business days.

Thank you for choosing Breitman Capital.
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