HealthCare United FCU Checking/Savings Account Application
Please print this form, fill it out and fax to
Close this Page

Account Information

Will there be a co-applicant on this application?    Yes    No

I am interested in:
    Checking Account
        Type of Checking Account:  ____________________________________________
        Initial Deposit Amount:  $_______________________________________________
        Source of Deposit:
           Transfer from a current account.   Account Number:  _____________________
           I will transfer funds from another institution.
           I will mail a check/money order.
           Other.   (please describe)  _________________________________________
    Savings Account
        Type of Savings Account:  _____________________________________________
        Initial Deposit Amount:  $_______________________________________________
        Source of Deposit:
           Transfer from a current account.   Account Number:  _____________________
           I will transfer funds from another institution.
           I will mail a check/money order.
           Other.   (please describe)  _________________________________________
    Other Account
        Description:  ________________________________________________________
        Initial Deposit Amount:  $_______________________________________________
        Source of Deposit:
           Transfer from a current account.   Account Number:  _____________________
           I will transfer funds from another institution.
           I will mail a check/money order.
           Other.   (please describe)  _________________________________________

I am also interested in:
    ATM Card
    ATM and Check/Debit Card
    Credit Card
    Direct Deposit
    Other   (please describe)  ______________________________________________

Primary Applicant

Last Name:

Member Number:

First Name:

Middle Name:

Social Security Number (TIN):

Date of Birth:

Home Phone Number:

Work Phone Number:

Other Phone Number:

Email Address:

Drivers License #:

Drivers License State:

Mother's Maiden Name:

Present Employer Name:

Address 1: 

Address 2: 

City:

State, Zip:

Co-Applicant

Last Name:

Member Number:

First Name:

Middle Name:

Social Security Number (TIN):

Date of Birth:

Home Phone Number:

Work Phone Number:

Other Phone Number:

Email Address:

Drivers License #:

Drivers License State:

Mother's Maiden Name:

Present Employer Name:

Address 1: 

Address 2: 

City:

State, Zip:

Additional Information

How would you prefer to be contacted?
  Home Phone
  Work Phone
  Other Phone
  Email Address
  Other:

Special Instructions/Comments:
 
 
 

Signatures

Primary Applicant Signature:

Date:        

Co-Applicant Signature:

Date: