Membership Form
230 Highland Ave. Somerville MA 02143
Phone: (617) 591-6710  •  Fax: (617) 591-6711
http://www.myhacu.org


How To Join
  1. Complete the following On-Line Membership Application Request Form and submit it.
  2. Once received, we will mail to you a pre-filled application form requiring your signature and the signature(s) of your joint owner(s) (if applicable).
  3. The signed Membership application must be returned to the credit union along with an initial deposit of at least $5.00 and / or payroll deduction form, and a copy of a government issued photo ID for the application process to be completed.

The Membership/Signature card you will sign includes the following statements and agreements:

I hereby make application for membership in Health Alliance Federal Credit Union (HAFCU), and agree to conform to its bylaws and amendments thereof, and to subscribe for at least one (1) share. HAFCU is hereby authorized to recognize any of the signatures subscribed hereto in the payment of funds or the transaction of any business for this account. The joint owners of this account hereby agree with each other and with HAFCU that all sums now paid in on shares, or heretofore or hereafter paid in on shares by any or all of said joint owners to their credit as such joint owners with all accumulations thereon, are and shall be owned by them jointly, with right of survivorship and be subject to the withdrawal or receipt of any of them, and payment to any of them or the survivor or survivors shall be valid and discharge said conditions of the account as established by the HAFCU from time to time. Any or all of said joint owners may pledge all or any part of the shares in this account as collateral security to a loan or loans from this Credit Union. The right, or authority of the HAFCU under this agreement shall not be changed or terminated by said owners, or any of them, except by written notice to HAFCU which shall not affect transactions theretofore made.

Under the penalties of perjury, I certify (1) that the number shown on this form is my correct taxpayer identification number and (2) that I am not subject to Backup Withholding either because I have not been notified that I am subject to back up withholding as a result of a failure to report all interest or dividends, OR The Internal Revenue Service has notified me that I am no longer subject to backup withholding, and (3) I am a U.S. citizen (including a U.S. resident alien).



Applicant Information
Applicant's Name:
Account #:
Social Security #:
Birthdate (MM/DD/YY):
Email Address :
Mothers's Maiden Name :
Driver’s License # :
Driver License Issue Date :
Driver License Expiration Date :
Driver License State of Issue :
Address :
City : State:
Zip #:
Home Phone #:
Cell Phone #:
Business Phone #:
Employer:
Occupation / Title:
Joint Applicant's Name:
Is Joint Applicant your spouse? Yes No
Social Security #:
Birthdate (MM/DD/YY):
Email Address :
Mother's Maiden Name:
Driver’s License # :
Driver License Issue Date :
Driver License Expiration Date :
Driver License State of Issue :
Address :
City : State:
Zip #:
Home Phone #:
Cell Phone #:
Business Phone #:
Employer:
Occupation / Title:

Beneficiary(s)
Name Social Security Relationship











Membership Eligibility (Please Select One)

CHA Employee     A retiree of CHA      Family member of CHA Employee

Related to Current Member

How did you hear about us?
Web Site
Billboard
Newspaper
Radio 		Search engine
Friend / Family -   Name:
Member/Co-Worker -  Name:
Other:

Submit Application

I/We understand that credit union membership is required to fully process this membership application and further documentation / signatures may be required. By submitting this form with your electronic signature(s), you agree that everything stated in this application is correct to the best of your knowledge and grant permission to the Credit Union to perform the following. The Credit Union is authorized to validate your information, investigate your creditworthiness, employment history, and obtain a credit report. You understand that any false or misleading statement in your application may cause any future loan or extension of credit to be in default. You authorize us to accept your facsimile signatures on this application and agree that your facsimile signature will have the same legal force and effect as your original signature. You assume any risk that may be associated with permitting us to accept your facsimile signature. The Credit Union may keep this application whether or not it is approved.

By pressing the "Submit Application" button below, you agree to the above statement.     

To avoid delays in processing your request please provide us with the best method and time to contact. Best method of contact:
 Home Phone      Mobile Phone      Work Phone      Email            What time of day is best to call:


Date:
 Primary Signature:
 Joint Signature: