HSA Membership Dues | ACH Info Submission

By submitting this form, you authorize HSA/HSUofCO to automatically withdraw your monthly membership dues from your selected account until the time of your graduation.*

Standard dues are $21.50/month. If you’d like, you may also choose to contribute at a higher giving level to provide additional support for HSA’s mission.

*You may revoke your membership by written notice to cuhousestaff@gmail.com.

Name

First Name

Last Name

Email

PGY Level

e.g. Intern = 1

Which level of Membership Dues would you like to commit to?

This membership will automatically end on your graduation date

Graduation Date

Please list the month and year you plan on graduating e.g. May 2030

Routing Number

Account Number

What type of account is this?

I authorize the deduction from my bank account for my membership dues to HSA/HSUofCO. I understand that I may revoke this authorization at any time by written notice.

I understand