Breakout Finance
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*Requires 3 Months of Most Recent Business Bank Statements
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Your Business
Legal Business Name
Include DBA name if applicable.
Business EIN
Type of Business
LLC
Corporation
Sole Proprietorship
Partnership
Other
Business Street Address
Business City
Business State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Other
Business Zip
Business Established Date
Business Industry
Agriculture
Apparel
Banking
Biotechnology
Chemicals
Communication
Construction
Consulting
Education
Electronics
Energy
Engineering
Entertainment
Environmental
Finance
Food & Beverage
Franchise
Government
Healthcare
Hospitality
Insurance
Machinery
Manufacturing
Media
Medical
Not For Profit
Other
Recreation
Retail
Shipping
Staffing
Technology
Telecommunications
Transportation
Utilities
Business Description
Describe products and/or services sold.
Loan Information
Requested Loan Amount
$25000
Primary Use of Proceeds
Working Capital
Expansion
Debt Consolidation
Other
Do You Have Outstanding Business Debt?
Yes
No
Current Lending Partners & Loan Balances?
List all institution(s) and estimated outstanding debt for each.
Customer Transactions
Business-to-Business
Business-to-Consumer
Both
Ownership Information
Primary Owner
First Name
Last Name
Email Address
Phone Number
Home Address
Provide street, city, state and zip code.
Date of Birth
Social Security Number
Years of Ownership
Percent Owned
0%
Ownership Information
Secondary Owner
2
First Name
2
Last Name
2
Email Address
2
Phone Number
2
Home Address
2
Provide street, city, state and zip code.
Date of Birth
2
Social Security Number
2
Years of Ownership
2
Percent Owned
2
0%
Documentation
Business Bank Statements
Upload 3 Months of Most Recent Statements
Drag and drop or browse files to upload (pdf, jpg or png).
Authorization to Access Consumer Credit File and UCC
By checking the box below, you understand and hereby agree that you are irrevocably authorizing Breakout Capital, LLC, a Delaware limited liability company (“Breakout”), its agents, counsel, representatives, and/or service providers (collectively with Breakout, “Breakout Parties”) to obtain your individual consumer report, including your credit score, and other information, for the purpose of verifying your identity and processing this application for financing (including loans and/or factoring). By signing below, you, on behalf of yourself, each business listed in this Application and each subsequent business for which you request financing (including loans and/or factoring) be provided by Breakout or an affiliate thereof hereby irrevocably authorize each Breakout Party or applicable affiliate to file at any time from and after the date hereof one or more Uniform Commercial Code financing statements in such offices as may be necessary, or in Breakout’s judgment desirable, to perfect any security interests in favor of Breakout or any affiliate thereof with respect to any or all personal property, assets and/or fixtures of each such authorizing party.
Yes, I Agree
Financing Application Acknowledgement
By submitting this application, you specifically represent to Breakout (the “Financing Party”) and agree and acknowledge that: (1) the information provided in this Financing Application and other requested and required information for the purposes of obtaining financing (including loans and/or factoring) is true, accurate, and complete as of the date this application is submitted for a credit or funding decision; and (2) the Financing Party has not made any commitment to approve the Financing Application or make any offer for funding, unless otherwise agreed to in writing.
Yes, I Agree
How Did You Hear About Us?
Referral
Online
Event
Other
Please Explain
Provide details on how you heard about us.
Who Is Your Business Development Officer?
N/A
David Balcom
Jason Bush
Grant Flamang
Greg Hitt
Ian Maddray
Andrew Moss
Brandon Murray
Zain Muzammal
Joshua Sapolich
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Contact Form Submitted
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Lead Type
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Product
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Lead Source
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