You can submit requests to update your account, manage your debit card, or re-order your debit card or PIN.

Customer Information

First Name

Last Name

SSN Last 4

Account Number Last 4

Account Maintenance Request

Maintenance Request Options

Change my legal full name

Change my permanent home address, mailing address or contact numbers

Reactivate my dormant account number

Add or change a beneficiary/POD on my account

Add accounts to my debit card

Re-order a new personal identification number (PIN)

Re-order my debit card due to damage

Request Information

Please enter only the information to be changed for the listed accounts.

Debit Card Last 6

Account Last 4

Beneficiary Action Type

Beneficiary Percentage

Legal First Name

Legal Middle Name

Legal Last Name

Address

Apt/Unit #

City

State

Zip

Mailing Address

Apt/Unit #

City

State

Zip

Home Phone

Cell Phone

Beneficiary Action Type

Beneficiary Percentage

Legal First Name

Legal Middle Name

Legal Last Name

Address

Apt/Unit #

City

State

Zip

Beneficiary Action Type

Beneficiary Percentage

Legal First Name

Legal Middle Name

Legal Last Name

Address

Apt/Unit #

City

State

Zip

Additional Details

Upload Supporting Documents

Please upload the following documents to support your request. If you are on a mobile device, you can easily take an image of the documents and upload.

Proof of address/phone verification item (ex. utility bill, phone bill, bank statement, tax form)
Upload file must not be greater than 5 Megabytes and must be in a PDF, JPG, JPEG or PNG format

Marriage Certificate or other Support Documentation

Proof of New Address

Proof of New Phone Numbers

Driver's License or Government Issued ID

Electronic Consent

By clicking on the "Submit Your Request" button below, I authorize Applied Bank to honor my request as indicated on this request form and represent to Applied Bank that all information given in this request is true, correct, and complete. I acknowledge that upon submission of the request form, Applied Bank will contact me to verify the request and no changes will be made to my account until such verification is complete. I further authorize Applied Bank to obtain any other information it believes is necessary to (i) complete this request, or (ii) provide any services Applied Bank extends to me as a result of this request. I acknowledge and agree that the Applied Bank Deposit Agreement and Terms and Conditions, as they both may be amended from time to time, govern my account including this submission.