Health Advantage Credit Union Membership Application

* Required Fields

Membership Qualification:

I am an employee, independent contractor, or self-employed person, who regularly works in the Health Care Industry in the State of Michigan

I am retired from the Health Care Industry in the State of Michigan

A member of my immediate family or household is an employee, independent contractor, or self- employed person, who regularly works in the Health Care Industry in the State of Michigan

First Name:

Last Name:

Birthdate:

/ /

Social Security:

- -

Mothers Maiden Name:

Driver's License/ID Number:

Expiration Date:

/ /

State Issued:

U.S. Citizen:

Yes

Address:

City:

State:

Zip Code:

Phone:

Email:

Employer/Title:

Patriot Act Notice

To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account. What this means for you: When you open an account, we are required to ask for your name, address, date of birth and other information that will allow us to identify you. We are also required to ask to see your driver's license or other identifying documents.

UPLOAD a color copy of your driver's license or state issued identification:

You are allowed an additional two (2) joint owners on your account, if applicable.

ADD JOINT OWNER 1 - IF APPLICABLE

First Name:

Last Name:

Birthdate:

/ /

Social Security:

- -

Mother's Maiden Name:

Driver's License/ID Number:

Expiration Date:

/ /

State Issued:

US Citizen:

Yes

Address 1:

Address 1 2:

City:

State:

ZIP:

Phone:

Email:

Employer/Title:

Patriot Act Notice

UPLOAD a color photo of your driver's license or state issued identification:

ADD JOINT OWNER 2 - IF APPLICABLE

First Name:

Last Name:

Birthdate:

/ /

Social Security:

- -

Mothers Maiden Name:

Driver's License/ID Number:

Expiration Date:

/ /

State Issued:

US Citizen:

Yes

Address 1:

Address 1 2:

City:

State:

ZIP:

Phone:

Email:

Employer/Title:

Patriot Act Notice

To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtains, verify, and record information that identifies each person who opens an accounts. What this means for you: When you open an account, we are required to ask for your name, address, date of birth and other information that will allow us to identify you. We are also required to ask to see your driver's license or other identifying documents.

UPLOAD a color copy of your driver's license or state issued identification:

CONSENT AND SUBMIT

Consent to access your personal credit profile

By clicking accept, I affirm all the information I provided is accurate and correct. I authorize Health Advantage Federal Credit Union to obtain my credit history. I understand that Health Advantage Federal Credit Union may contact me for additional information. Health Advantage Federal Credit Union may obtain information from others about me and give information to others, including but not limited to verifying my identity and performing authentications as required by applicable local, state, and federal regulation.

By clicking accept, I acknowledge that I have read and understood Health Advantage Federal Credit Union's Deposit Account Contract, which includes the Funds Availability, Electronic Fund Transfer, Privacy Policy, and Rate & Fee Disclosures. I understand that the Health Advantage Federal Credit Union Deposit Account Contract governs my membership and current and future accounts, products, services, and other aspects of my relationship with Health Advantage Federal Credit Union. I understand that Health Advantage Federal Credit Union may change their Deposit Account Contract at any time and notify me of any changes within 60 days.

By submitting this application electronically to Health Advantage Federal Credit Union, I agree to the same terms that apply to a signed application. I also understand an owner may conduct transactions on and start, maintain, change, add or terminate accounts, products and services as explained in the Deposit Account Contract. If there are joint owners on this application, that co-applicant has authorized the submission of this application. This electronic submission qualifies as my signature. I agree Health Advantage Federal Credit Union may rely solely on this Member Application and have no obligation to rely on any other documents. I understand that I/We may have to sign additional documents before my new membership is processed.

Tax Information Certification

By electronically signing and selecting Submit, I certify under penalties of perjury that: (i) I am a US citizen or other US person, (ii) the Social Security Number (SSN)/Employer Identification Number (EIN) shown is my/the correct identification number and (iii) I am NOT, unless designated below, subject to backup withholding because I am exempt or I have not been notified by the IRS that I am subject to backup withholding as a result of a failure to report all dividends or interest, or because the IRS has notified me that I am no longer subject to backup withholding.

The Internal Revenue Service does not require your consent to any provision of the Member Service Agreement other than the certification required to avoid backup withholding.

Tax Information Certification:

I am subject to backup withholding

Exempt

I am not a United States citizen or resident

Do you authorize Health Advantage Federal Credit Union to obtain your credit report and process this application for membership?

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