HSA to Checking Application

Complete this application to open a checking account.

Do you have an existing HSA with us? Fill out the form below to apply for our Basic Checking Account.

* Required

*Company/Organization Name

Application Type

Individual

Joint

*First Name

Middle Name

*Last Name

*Email Address

*Phone Number

*Social Security Number

*Driver's License #

*License State

*License Issue Date

*Licene Expiration Date

Address (P.O. Box not allowed)

*Street Address

*City

*State

*Zip Code

*Status

Renting

Own

*Years at Residence

*Date of Birth

*Select 4-digit pin for Debit/ATM Card

Agreement

I (we) apply for membership in this credit union, agree to follow its by-laws and amendments and subscribe for at least one share. This membership agreement applies to the accounts indicated. I (we) authorize the credit union to investigate my (our) credit and request that the credit union issue me (us) a PIN (personal identification number) to access the MATT Audio Response System. The credit union will mail a fee schedule, a copy of the terms and conditions applicable to each account applied for, and the Funds Availability, Electronic Fund Transfer and Truth in Savings Disclosures within twenty days.

The USA PATRIOT Act has paved the way for financial institutions to help prevent fraud, identity theft, and the spread of terrorism. It requires financial institutions to obtain more information from an individual or legal entity to help establish identity.

*Do you authorize Mid American Credit Union to share your account information with your employer for the purpose of setting up and maintaining direct deposits into your account?

Yes

Note: By selecting 'No', you will be responsible for communicating necessary account information to your employer.

*Signature

*Date

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Success!

Your application has been submitted. You will receive an email from a Mid American representative within the next 48 hours to complete your online application.