Membership Enrollment Form
 946 East Third Street, Chattanooga, TN 37403
Phone: (423) 242-4728 • Fax: (423) 242-1940

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 $25.00 and / or direct deposit form, and a copy of a government issued photo ID for you and any other joint owners 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 Healthcare Services Credit Union, and agree to conform to its bylaws and amendments thereof, and to subscribe for at least one (1) share. The Healthcare Services CU 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 Healthcare Services CU 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 Healthcare Services CU 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 Healthcare Services CU under this agreement shall not be changed or terminated by said owners, or any of them, except by written notice to Healthcare Services CU 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
First Name: MI: Physical Address :
Last Name: City : State:
Date of Birth: Zip :
Mother's Maiden Name: Mailing Address :
Social Security #: City : State:
Driver’s License # : Zip :
Driver License Issue Date : Home Phone :
Driver License Expiration Date : Business Phone :
Driver License State of Issue : Employer:
Email Address : Occupation / Title:

Will this be a joint account?
Yes        If yes, joint owner’s name:

Name Social Security Relationship

How did you hear about us?
Web Site
Movie theater
Search engine
Friend / Family -   Name:
Member/Co-Worker -  Name:

Submit Application

I/We understand that credit union membership is required to fully process this membership form 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 Healthcare Services Credit Union to perform the following. Healthcare Services CU is authorized to validate your information, investigate your creditworthiness, employment history, and obtain a credit report. We will validate their information but we don’t run credit reports or investigate creditworthiness when someone opens an account) . You understand that any false or misleading statement in your application may cause any loan or extension of credit to be in default. You authorize us to accept your facsimile signatures on this application until original signature are received from you 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. Healthcare Services CU may keep this application whether or not it is approved.

By pressing the "Submit Form" 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          What time of day is best to call:

Primary Signature:
Joint Signature:
Enter The Security Code Displayed In The Box Below: