[PRUDENTIAL LOGO] Exhibit 4(a) Pruco Life Insurance Company of New Jersey, STRATEGIC PARTNERS SELECT(SM) a Prudential company VARIABLE ANNUITY APPLICATION Flexible Payment Variable Deferred Annuity - -------------------------------------------------------------------------------- [?] On these pages, I, you, and your refer to the contract owner. We, us, and our refer to Pruco Life Insurance Company of New Jersey, a Prudential company. - -------------------------------------------------------------------------------- [1] CONTRACT Contract number (if any) 123456789 OWNER INFORMATION [X] Individual [ ] Corporation [ ] UGMA/UTMA [ ] Other TRUST: [ ] Grantor [ ] Revocable [ ] Irrevocable TRUST DATE (mo., day, year) -- -- ---- Name of owner (first, middle initial, last name) John Doe --------------------------------------------------------------- Street Apt. 123 Main Street --------------------------------------------- --------------- City State ZIP code ANYTOWN NJ 07101-0000 ------------------------- --- ----------------- Social Security number/TIN 123456789 ------------------------------ Date of birth (mo., day, year) 04251948 ------------------------------ Telephone number 888 555-5555 ------------------------------ [ ] Female [x] U.S. citizen [X] Male [ ] Resident alien [ ] I am not a U.S. citizen or resident alien. I am a citizen of: ----------------------------------------------------------- If a corporation or trust is indicated above, please check the following as it applies. [ ] Tax-exempt entity under IRS Code 501 [ ] Trust acting as agent for an individual under IRS Code 72(u) - -------------------------------------------------------------------------------- [2] JOINT Name of joint owner (first, middle initial, last name) OWNER Mary Doe INFORMATION --------------------------------------------------------------- (if any) Do not Street (Leave address blank if same as owner.) complete if you are --------------------------------------------------------------- opening an IRA. City State ZIP code ------------------------- --- ----------------- Social Security number/TIN 987654321 ------------------------------ Date of birth (mo., day, year) 05141950 ------------------------------ Telephone number 888 555-5555 ------------------------------ [X] Female [X] U.S. citizen [ ] Male [ ] Resident alien [ ] I am not a U.S. citizen or resident alien. I am a citizen of: ----------------------------------------------------------- - -------------------------------------------------------------------------------- [3] ANNUITANT This section must be completed only if the annuitant is not the INFORMATION owner or if the owner is a trust or a corporation. (if different Name of annuitant (first, middle initial, last name) than the owner) --------------------------------------------------------------- Street (Leave address blank if same as owner.) Apt. --------------------------------------------- --------------- City State ZIP code ------------------------- --- ----------------- Social Security number/TIN ------------------------------ Date of birth (mo., day, year) ------------------------------ Telephone number ------------------------------ [ ] Female [ ] U.S. citizen [ ] Male [ ] Resident alien [ ] I am not a U.S. citizen or resident alien. I am a citizen of: ----------------------------------------------------------- - -------------------------------------------------------------------------------- PRUCO CORPORATE OFFICE: Pruco Life Insurance Company of New Jersey, Newark, NJ 07102 [ORD 99669 NEW YORK] Page 1 of 6 Ed. 5/2001 - -------------------------------------------------------------------------------- |1| CO-ANNUITANT Name of co-annuitant (first, middle initial, last name) INFORMATION (if any) Do not |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| complete if Social Security number/TIN Date of birth (mo., day, year) you are |_|_|_|_|_|_|_|_|_| |_|_| |_|_| |_|_|_|_| opening Telephone number an IRA. |_|_|_| |_|_|_|-|_|_|_|_| [ ] Female [ ] U.S. citizen [ ] Male [ ] Resident alien [ ] I am not a U.S. citizen or resident alien. I am a citizen of |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| - -------------------------------------------------------------------------------- |2| BENEFICIARY [X] PRIMARY CLASS INFORMATION Name of beneficiary (first, middle initial, last name) (Please add If trust, include name of trust and trustee's name. additional |M|A|R|Y|_|D|O|E|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| benefi- TRUST: [ ] Revocable [ ]Irrevocable ciaries in Trust date (mo., day, year) |_|_| |_|_| |_|_|_|_| section 15.) Beneficiary's relationship to annuitant |S|P|O|U|S|E|_|_|_|_|_|_|_|_|_| CHECK ONLY ONE: [ ] Primary class [ ] Secondary class Name of beneficiary (first, middle initial, last name) If trust, include name of trust and trustee's name. |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| TRUST: [ ] Revocable [ ] Irrevocable Trust date (mo., day, year) |_|_| |_|_| |_|_|_|_| Beneficiary's relationship to annuitant |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| - -------------------------------------------------------------------------------- |3| TYPE OF PLAN TYPE. Check only one: PLAN AND SOURCE [X] Non-qualified [ ] Traditional IRA OF ------------------------------------------------------------------- FUNDS (minimum SOURCE OF FUNDS. Check all that apply: of $10,000) [X] Total amount of the check(s) included with this application. (Make checks payable to Prudential.) $|_|_|, |_|1|0|, |0|0|0|.|0|0| [ ] IRA Rollover $|_|_|, |_|_|_|, |_|_|_|, _|_|_| If Traditional IRA, new contribution(s) for the current and/or previous year, complete the following: $|_|_|, |_|_|_|.|_|_| Year |_|_|_|_| $|_|_|, |_|_|_|.|_|_| Year |_|_|_|_| [ ] 1035 Exchange (non-qualified only), estimated amount: $|_|_|, |_|_|_|,|_|_|_|.|_|_| [ ] IRA Transfer (qualified), estimated amount: $|_|_|, |_|_|_|,|_|_|_|.|_|_| [ ] Direct Rollover (qualified), estimated amount: $|_|_|, |_|_|_|,|_|_|_|.|_|_| - -------------------------------------------------------------------------------- [ORD 99669 NEW YORK] Page 2 of 6 Ed. 5/2001 - -------------------------------------------------------------------------------- /7/ PURCHASE Please write in the percentage of your payment that you want PAYMENT to allocate to the following options. The total must equal ALLOCATION(S) 100 percent. IF CHANGES ARE MADE TO THE ALLOCATIONS LISTED BELOW, THE APPLICANT MUST INITIAL THE CHANGES. <Table> <Caption> OPTION OPTION INTEREST RATE OPTIONS CODES % VARIABLE INVESTMENT OPTIONS (continued) CODES % - ------------------------------------------------------------------------------------------------------------------------------------ [1 Year Fixed-Rate Option 1YRFXD SP Davis Value Portfolio VALUE - ------------------------------------------------------------------------------------------------------------------------------------ 7 Year Market Value Adjustment Option 7YRMVA SP Deutsche International Equity Portfolio DEUEQ - ------------------------------------------------------------------------------------------------------------------------------------ VARIABLE INVESTMENT OPTIONS SP Growth Asset Allocation Portfolio GRWAL - ------------------------------------------------------------------------------------------------------------------------------------ Prudential Global Portfolio GLEQ 50 SP INVESCO Small Company Growth Portfolio VIFSG - ------------------------------------------------------------------------------------------------------------------------------------ Prudential Jennison Portfolio GROWTH 50 SP Jennison International Growth Portfolio JENIN - ------------------------------------------------------------------------------------------------------------------------------------ Prudential Money Market Portfolio MMKT SP Large Cap Value Portfolio LRCAP - ------------------------------------------------------------------------------------------------------------------------------------ Prudential Stock Index Portfolio STIX SP MFS Capital Opportunities Portfolio MFSCO - ------------------------------------------------------------------------------------------------------------------------------------ SP Aggressive Growth Asset Allocation Portfolio AGGGW SP MFS Mid Cap Growth Portfolio MFSMC - ------------------------------------------------------------------------------------------------------------------------------------ SP AIM Aggressive Growth Portfolio AIMAG SP PIMCO High Yield Portfolio HIHLD - ------------------------------------------------------------------------------------------------------------------------------------ SP AIM Growth and Income Portfolio AIMGI SP PIMCO Total Return Portfolio RETRN - ------------------------------------------------------------------------------------------------------------------------------------ SP Alliance Large Cap Growth Portfolio LARCP SP Prudential U.S. Emerging Growth Portfolio EMRGW - ------------------------------------------------------------------------------------------------------------------------------------ SP Alliance Technology Portfolio ALLTC SP Small/Mid Cap Value Portfolio SMDVL - ------------------------------------------------------------------------------------------------------------------------------------ SP Balanced Asset Allocation Portfolio BALAN SP Strategic Partners Focus Growth Portfolio STRPR - ------------------------------------------------------------------------------------------------------------------------------------ SP Conservative Asset Allocation Portfolio CONSB Janus Aspen Series Growth Portfolio-Service Shares JANSR ] - ------------------------------------------------------------------------------------------------------------------------------------ TOTAL 100% - ------------------------------------------------------------------------------------------------------------------------------------ </Table> - -------------------------------------------------------------------------------- /8/ DOLLAR COST / / DOLLAR COST AVERAGING: I authorize Prudential to AVERAGING automatically transfer funds as indicated below: PROGRAM TRANSFER FROM: (You cannot transfer from the 7 Year Market Value Adjustment Option.) Option Code: $ , , . or % TRANSFER FREQUENCY: / / Annually / / Semiannually / / Quarterly / / Monthly TRANSFER TO: (You cannot transfer to the Interest Rate Options.) The total of the two columns must equal 100 percent. OPTION CODE PERCENT OPTION CODE PERCENT % % % % % % I understand that the transfer will continue until: (1) I terminate the program; (2) the funds in the account from which money is being transferred are exhausted; or (3) the funds in the account fall below the required minimum. I also understand that the Dollar Cost Averaging (DCA) programs are described in and subject to the rules and restrictions contained in the prospectus. - -------------------------------------------------------------------------------- - -------------------- Page 3 of 6 ed. 5/2001 ORD 99669 New York - -------------------- ________________________________________________________________________________ 9 AUTO- [ ] AUTO-REBALANCING: I want to maintain my allocation REBALANCING percentages. Please have my portfolio mix automatically adjusted as allocated in section 7 under my variable investment options. Adjust my portfolio: [ ] Annually [ ] Semiannually [ ] Quarterly [ ] Monthly Please specify the start date if different than the contract date: --------- month day year ________________________________________________________________________________ 10 AUTOMATED [ ] AUTOMATED WITHDRAWAL: I would like to elect automatic WITHDRAWALS withdrawals from my annuity contract. Automated withdrawals can be made monthly, quarterly, semiannually, or annually. The amount of each withdrawal must be at least $100. You must complete the Request for Partial or Automated Withdrawal form (ORD 78276) in order to specify start date, frequency, and amount of withdrawals. NOTE: AUTOMATIC WITHDRAWALS CANNOT BE USED TO CONTINUE THE CONTRACT BEYOND THE MATURITY DATE. ON THE MATURITY DATE THE CONTRACT MUST ANNUITIZE. ________________________________________________________________________________ 11 AGGREGATION [ ] I have purchased another non-qualified annuity from (non-qualified Prudential or an affiliated company this calendar annuities only) year. Contract number ----------------- ________________________________________________________________________________ 12 REPLACEMENT THIS SECTION MUST BE COMPLETED. (Please enter additional Will the proposed annuity contract replace any existing comments in insurance policy(ies) or annuity contract(s)? section 15.) [ ] Yes [X] No If "Yes," provide the following information for each policy or contract and attach all applicable Prudential disclosure and state replacement forms. Company name -------------------------------------------- Policy or contract number Year of issue (mo, day, year) ------------------------- ----------------------------- Name of plan (if applicable) ---------------------------- THIS QUESTION MUST BE COMPLETED BY THE REPRESENTATIVE. Do you have, from any source, facts that any person named as the owner or joint owner above is replacing or changing any current insurance or annuity in any company? [ ] Yes [X] No ________________________________________________________________________________ 13 SIGNATURE(S) If applying for an IRA, I acknowledge receiving an IRA disclosure statement and understand that I will be given a financial disclosure statement with the contract. I understand that tax deferral is provided by the IRA, and acknowledge that I am purchasing this contract for its features other than tax deferral, including the lifetime income payout option, the Death Benefit protection, the ability to transfer among investment options without sales or withdrawal charges, and other features as described in the prospectus. No representative can make or change a contract or waive any of the rights. I believe that this contract meets my needs and financial objectives. Furthermore, I (1) understand that any amount of purchase payments allocated to a variable investment option will reflect the investment experience of that option and, therefore, annuity payments and surrender values may vary and are not guaranteed as to a fixed dollar amount, and (2) acknowledge receipt of the current prospectus for this contract and the variable investment options. (continued) ________________________________________________________________________________ ORD 99669 New York Page 4 of 6 Ed. 5/2001 SIGNATURE(S) [ ] If this contract has a joint owner, please check this box to (continued) authorize Prudential to act on the instruction(s) of either the owner or joint owner with regard to transactions under the contract. [ ] If this application is being signed at the time the contract is delivered, I acknowledge receipt of the contract. [ ] Check here to request a Statement of Additional Information. MINIMUM DISTRIBUTION UNDER AN IRA: IF YOU HAVE NOT MET THE REQUIRED MINIMUM DISTRIBUTION FOR THE YEAR IN WHICH THE FUNDS ARE PAID TO PRUDENTIAL: I understand it is my responsibility to remove the minimum distribution from the purchase payment prior to sending money to Prudential with this application. Unless we are notified otherwise, Prudential will assume that the owner is satisfied with the required minimum distributions from other IRA funds. By signing this form, the trustee(s)/officer(s) hereby represents that the trustee(s)/officer(s) possess(es) the authority, on behalf of the non-natural person, to purchase the annuity contract and to exercise all rights of ownership and control over the contract, including the right to make purchase payments to the contract. I understand that any amount of purchase payments allocated to the MVA option may increase or decrease due to such adjustment prior to the maturity of the interest cell. OWNER'S TAX CERTIFICATION ------------------------------------------------------------------ Under penalty of perjury, I certify that the taxpayer identification number (TIN) I have listed on this form is my correct taxpayer identification number, I HAVE/HAVE NOT (circle one) been notified by the Internal Revenue Service that I am subject to backup withholding due to underreporting of interest or dividends. ------------------------------------------------------------------ THE INTERNAL REVENUE SERVICE DOES NOT REQUIRE YOUR CONSENT TO ANY PROVISION OF THIS DOCUMENT OTHER THAN THE CERTIFICATIONS REQUIRED TO AVOID BACKUP WITHHOLDING. ------------------------------------------------------------------ We must have both the owner's and annuitant's signatures even if this contract is owned by a trust, corporation, or other entity. If the annuitant is a minor, please provide the signature of a legal guardian or custodian. I hereby certify that all the information contained in this application is complete and true to the best of my knowledge. X /s/ John Doe 05 04 2001 --------------------------------------- -- -- ---- Contract owner's signature and date month day year X /s/ Mary Doe 05 04 2001 --------------------------------------- -- -- ---- Joint owner's signature (if applicable) month day year and date X /s/ John Doe 05 04 2001 --------------------------------------- -- -- ---- Annuitant's signature (if applicable) month day year and date X --------------------------------------- -- -- ---- Co-annuitant's signature (if applicable) month day year and date /s/ Anytown, N.J. --------------------------------------- Signed at (city, state) - -------------------------------------------------------------------------------- ORD 99669 New York Page 5 of 6 Ed. 5/2001 ================================================================================ 14 REPRESEN- Commission Option (For Retail Distribution only. Choose only TATIVE'S one.): SIGNATURE(S) 1. [ ] No Trail 2. [ ] Mid Trail 3. [ ] High Trail Note: If an option is not selected, the default option will be Option 3. This application is submitted in the belief that the purchase of this contract is appropriate for the applicant based on the information provided and as reviewed with the applicant. Reasonable inquiry has been made of the owner concerning the owner's overall financial situation, needs, and investment objectives. The representative hereby certifies that all information contained in this application is true to the best of his or her knowledge. /s/ Richard Roe 123456789 ------------------------------------------- ---------------- Representative's name (Please print) Rep's contract/ FA number X /s/ Richard Roe 05 04 2001 ------------------------------------------- ---------------- Representative's signature and date month day year ------------------------------------------- ---------------- Second representative's name (Please print) Rep's contract/ FA number X ------------------------------------------- --------------- Second representative's signature and date month day year /s/ Sunnytown - SNTN 888 555-5555 ------------------------------------------- ---------------- Branch/field office name and code Representative's telephone number ================================================================================ 15 ADDITIONAL REMARKS ------------------------------------------------------------------ ------------------------------------------------------------------ ------------------------------------------------------------------ ------------------------------------------------------------------ ------------------------------------------------------------------ ------------------------------------------------------------------ ------------------------------------------------------------------ ------------------------------------------------------------------ ================================================================================ STANDARD PRUDENTIAL ANNUITY SERVICE CENTER MAIL TO: PO BOX 7590 PHILADELPHIA, PA 19101 OVERNIGHT PRUDENTIAL ANNUITY SERVICE CENTER MAIL TO: 2101 WELSH ROAD DRESHER, PA 19025 If you have any questions, please call the Prudential Annuity Service Center at (888) 778-2888, Monday through Friday between 8:00 a.m. and 8:00 p.m. Eastern time. ================================================================================ ORD 99669 New York Page 6 of 6 Ed. 5/2001 [PRUDENTIAL LOGO] PRUDENTIAL STRATEGIC PARTNERS SELECT(SM) Pruco Life Insurance VARIABLE ANNUITY APPLICATION Company of New Jersey, Flexible Payment Variable a Prudential company Deferred Annuity - -------------------------------------------------------------------------------- On these pages, I, you, and your refer to the contract owner. We, us, and our refer to Pruco Life Insurance Company of New Jersey, a Prudential company. - -------------------------------------------------------------------------------- 1 CONTRACT Contract number (if any) 123456789 OWNER [X] Individual [ ] Corporation [ ] UGMA/UTMA [ ] Other INFORMATION TRUST: [ ] Grantor [ ] Revocable [ ] Irrevocable TRUST DATE (mo., day, year) -------------------- Name of owner (first, middle initial, last name) JOHN DOE ------------------------------------------------------------- Street Apt. 123 MAIN STREET ------------------------------------------------------------- City State ZIP code ANYTOWN NY 07101-0000 ------------ --------- -------------- Social Security number/TIN Date of birth (mo., day, year) 123456789 04 25 1948 -------------------------- -------------------------------- Telephone number 888 555-5555 -------------------------- [ ] Female [X] U.S. citizen [ ] I am not a U.S. [X] Male [ ] Resident alien citizen or resident alien. I am a citizen of ---------------------- If a corporation or trust is indicated above, please check the following as it applies. [ ] Tax-exempt entity under IRS Code 501 [ ] Trust acting as agent for an individual under IRS Code 72(u) - -------------------------------------------------------------------------------- 2 JOINT Name of joint owner (first, middle initial, last name) OWNER MARY DOE INFORMATION ------------------------------------------------------------- (if any) Do not Street (Leave address blank if same as owner.) Apt. complete if you are ------------------------------------------------------------- opening an IRA. City State ZIP code ------------ --------- -------------- Social Security number/TIN Date of birth (mo., day, year) 987654321 05 17 1950 -------------------------- -------------------------------- Telephone number 888 555-5555 -------------------------- [X] Female [X] U.S. citizen [ ] I am not a U.S. [ ] Male [ ] Resident alien citizen or resident alien. I am a citizen of ---------------------- - -------------------------------------------------------------------------------- 3 ANNUITANT This section must be completed only if the annuitant is not INFORMATION the owner or if the owner is a trust or a corporation. (if different than the Name of annuitant (first, middle initial, last name) owner) ------------------------------------------------------------- Street (Leave address blank if same as owner.) Apt. ------------------------------------------------------------- City State ZIP code ------------ --------- -------------- Social Security number/TIN Date of birth (mo., day, year) -------------------------- -------------------------------- Telephone number -------------------------- [ ] Female [ ] U.S. citizen [ ] I am not a U.S. [ ] Male [ ] Resident alien citizen or resident alien. I am a citizen of ---------------------- - -------------------------------------------------------------------------------- Pruco Corporate Office: Pruco Life Insurance Company of New Jersey, Newark NJ 07102 ORD 99669 New York - Third Party Page 1 of 6 Ed. 5/2001 Third Party - -------------------------------------------------------------------------------- /4/ CO-ANNUITANT Name of co-annuitant (first, middle initial, last name) INFORMATION (if any) ------------------------------------------------------------ Do not complete if Social Security number/TIN Date of birth (mo., day, year) you are opening an -------------------------- -- -- ---- IRA. Telephone Number --- -------- / / Female / / U.S. citizen / / Male / / Resident alien / / I am not a U.S. citizen or resident alien. I am a citizen of -------------------------------------------------------- - -------------------------------------------------------------------------------- /5/ BENEFICIARY /X/ PRIMARY CLASS INFORMATION Name of beneficiary (first, middle initial, last name). (Please add If trust, include name of trust and trustee's name. additional Mary Doe beneficiaries ------------------------------------------------------------ in section 15.) TRUST: / / Revocable / / Irrevocable Trust date (mo., day, year) -- -- ---- Beneficiary's relationship to annuitant SPOUSE -------------------- CHECK ONLY ONE: / / Primary class / / Secondary class Name of beneficiary (first, middle initial, last name). If trust, include name of trust and trustee's name. ------------------------------------------------------------ TRUST: / / Revocable / / Irrevocable Trust date (mo., day, year) -- -- ---- Beneficiary's relationship to annuitant -------------------- - -------------------------------------------------------------------------------- /6/ TYPE OF PLAN PLAN TYPE. Check only one: AND SOURCE OF /X/ Non-qualified / / Traditional IRA FUNDS (minimum of ------------------------------------------------------------ $10,000) SOURCE OF FUNDS. Check all that apply: /X/ Total amount of the check(s) included with this application. (Make checks payable to Prudential.) $ 10,000.00 -- ,--- --- -- / / IRA Rollover $ , , . -- --- --- -- If Traditional IRA, new contribution(s) for the current and/or previous year, complete the following: $ , . Year $ , . Year - --- -- ---- - --- -- ---- / / 1035 Exchange (non-qualified only), estimated amount: $ , , . -- --- --- -- / / IRA Transfer (qualified), estimated amount: $ , , . -- --- --- -- / / Direct Rollover (qualified), estimated amount: $ , , . -- --- --- -- - -------------------------------------------------------------------------------- - ---------------------------------- Page 2 of 6 Ed. 5/2001 Third Party ORD 99669 New York - Third Party - ---------------------------------- ________________________________________________________________________________ 7 PURCHASE Please write in the percentage of your payment that you PAYMENT want to allocate to the following options. The total must ALLOCATION(S) equal 100 percent. IF CHANGES ARE MADE TO THE ALLOCATIONS LISTED BELOW, THE APPLICANT MUST INITIAL THE CHANGES. <Table> <Caption> OPTION OPTION INTEREST-RATE OPTIONS CODES % VARIABLE INVESTMENT OPTIONS (continued) CODES % - --------------------- ----- --- --------------------------------------- ------- --- 1 Year Fixed-Rate Option 1YRFXD SP Davis Value Portfolio VALUE 7 Year Market Value Adjustment Option 7YRMVA SP Deutsche International Equity Portfolio DEUEQ VARIABLE INVESTMENT OPTIONS SP Growth Asset Allocation Portfolio GRWAL Prudential Global Portfolio GLEQ 50 SP INVESCO Small Company Growth Portfolio VIFSG Prudential Jennison Portfolio GROWTH 50 SP Jennison International Growth Portfolio JENIN Prudential Money Market Portfolio MMKT SP Large Cap Value Portfolio LRCAP Prudential Stock Index Portfolio STIX SP MFS Capital Opportunities Portfolio MFSCO SP Aggressive Growth Asset Allocation Portfolio AGGGW SP MFS Mid Cap Growth Portfolio MFSMC SP AIM Aggressive Growth Portfolio AIMAG SP PIMCO High Yield Portfolio HIHLD SP AIM Growth and Income Portfolio AIMGI SP PIMCO Total Return Portfolio RETRN SP Alliance Large Cap Growth Portfolio LARCP SP Prudential U.S. Emerging Growth Portfolio EMRGW SP Alliance Technology Portfolio ALLTC SP Small/Mid Cap Value Portfolio SMDVL SP Balanced Asset Allocation Portfolio BALAN SP Strategic Partners Focus Growth Portfolio STRPR SP Conservative Asset Allocation Portfolio CONSB Janus Aspen Series Growth Portfolio-Service Shares JANSR TOTAL 100% ________________________________________________________________________________ 8 DOLLAR COST [ ] DOLLAR COST AVERAGING: I authorize Prudential to AVERAGING automatically transfer funds as indicated below. PROGRAM TRANSFER FROM: (You cannot transfer from the 7 Year Market Value Adjustment Option.) Option code: ------ $--,---,---.-- or ----% TRANSFER FREQUENCY: [ ] Annually [ ] Semiannually [ ] Quarterly [ ] Monthly TRANSFER TO: (You cannot transfer to the Interest Rate Options.) The total of the two columns must equal 100 percent. <Table> <Caption> Option code Percent Option code Percent ----------- ------- ----------- ------- ------ ---% ------ ---% ------ ---% ------ ---% ------ ---% ------ ---% I understand that the transfer will continue until: (1) I terminate the program; (2) the funds in the account from which money is being transferred are exhausted; or (3) the funds in the account fall below the required minimum. I also understand that the Dollar Cost Averaging (DCA) programs are described in and subject to the rules and restrictions contained in the prospectus. ________________________________________________________________________________ ORD 99669 NEW YORK - THIRD PARTY Page 3 of 6 Ed. 5/2001 Third Party ________________________________________________________________________________ 9 AUTO- / / AUTO-REBALANCING: I want to maintain my allocation percentages. REBALANCING Please have my portfolio mix automatically adjusted as allocated in section 7 under my variable investment options. Adjust my portfolio: / / Annually / / Semiannually / / Quarterly / / Monthly Please specify the start date if different than the contract date: -- -- ---- month day year ________________________________________________________________________________ 10 AUTOMATED / / AUTOMATED WITHDRAWAL: I would like to elect automatic WITHDRAWALS withdrawals from my annuity contract. Automated withdrawals can be made monthly, quarterly, semiannually, or annually. The amount of each withdrawal must be at least $100. You must complete the Request for Partial or Automated Withdrawal form (P-ORD 78276) in order to specify start date, frequency, and amount of withdrawals. NOTE: AUTOMATIC WITHDRAWALS CANNOT BE USED TO CONTINUE THE CONTRACT BEYOND THE MATURITY DATE. ON THE MATURITY DATE THE CONTRACT MUST ANNUITIZE. ________________________________________________________________________________ 11 AGGREGATION / / I have purchased another non-qualified annuity from (non-qualified Prudential or an affiliated company this calendar year. annuities only) Contract number --------- ________________________________________________________________________________ 12 REPLACEMENT THIS SECTION MUST BE COMPLETED. (Please enter additional Will the proposed annuity contract replace any existing comments in insurance policy(ies) or annuity contract(s)? section 15.) / / Yes /X/ No If "Yes," provide the following information for each policy or contract and attach all applicable Prudential disclosure and state replacement forms. Company name ----------------------------------------------------------- Policy or contract number Year of issue Name of plan (if applicable) (mo., day, year) - ---------------------- -- -- ---- ------------------------- THIS QUESTION MUST BE COMPLETED BY THE FINANCIAL PROFESSIONAL. Do you have, from any source, facts that any person named as the owner or joint owner above is replacing or changing any current insurance or annuity in any company? / / Yes /X/ No ________________________________________________________________________________ 13 SIGNATURES If applying for an IRA, I acknowledge receiving an IRA disclosure statement and understand that I will be given a financial disclosure statement with the contract. I understand that tax deferral is provided by the IRA, and acknowledge that I am purchasing this contract for its features other than tax deferral, including the lifetime income payout option, the Death Benefit protection, the ability to transfer among investment options without sales or withdrawal charges, and other features as described in the prospectus. No representative can make or change a contract or waive any of the rights. I believe that this contract meets my needs and financial objectives. Furthermore, I (1) understand that any amount of purchase payments allocated to a variable investment option will reflect the investment experience of that option and, therefore, annuity payments and surrender values may vary and are not guaranteed as to a fixed dollar amount, and (2) acknowledge receipt of the current prospectus for this contract and the variable investment options. (continued) ________________________________________________________________________________ ORD 99669 New York - Third Party Page 4 of 6 Ed. 5/2001 Third Party 13 SIGNATURE(S) [ ] If this contract has a joint owner, please check this box to (continued) authorize Prudential to act on the instruction(s) of either the owner or joint owner with regard to transactions under the contract. [ ] If this application is being signed at the time the contract is delivered, I acknowledge receipt of the contract. [ ] Check here to request a Statement of Additional Information. MINIMUM DISTRIBUTION UNDER AN IRA: IF YOU HAVE NOT MET THE REQUIRED MINIMUM DISTRIBUTION FOR THE YEAR IN WHICH THE FUNDS ARE PAID TO PRUDENTIAL: I understand it is my responsibility to remove the minimum distribution from the purchase payment prior to sending money to Prudential with this application. Unless we are notified otherwise, Prudential will assume that the owner is satisfied with the required minimum distributions from other IRA funds. By signing this form, the trustee(s)/officer(s) hereby represents that the trustee(s)/officer(s) possess(es) the authority, on behalf of the non-natural person, to purchase the annuity contract and to exercise all rights of ownership and control over the contract, including the right to make purchase payments to the contract. I understand that any amount of purchase payments allocated to the MVA option may increase or decrease due to such adjustment prior to the maturity of the interest cell. OWNER'S TAX CERTIFICATION ------------------------------------------------------------------ Under penalty of perjury, I certify that the taxpayer identification number (TIN) I have listed on this form is my correct taxpayer identification number. I HAVE/HAVE NOT (circle one) been notified by the Internal Revenue Service that I am subject to backup withholding due to underreporting of interest or dividends. ------------------------------------------------------------------ THE INTERNAL REVENUE SERVICE DOES NOT REQUIRE YOUR CONSENT TO ANY PROVISION OF THIS DOCUMENT OTHER THAN THE CERTIFICATIONS REQUIRED TO AVOID BACKUP WITHHOLDING. ------------------------------------------------------------------ We must have both the owner's and annuitant's signatures even if this contract is owned by a trust, corporation, or other entity. If the annuitant is a minor, please provide the signature of a legal guardian or custodian. I hereby certify that all the information contained in this application is complete and true to the best of my knowledge. X /s/ John Doe 05 04 2001 --------------------------------------- -- -- ---- Contract owner's signature and date month day year X /s/ Mary Doe 05 04 2001 --------------------------------------- -- -- ---- Joint owner's signature (if applicable) month day year and date X /s/ John Doe 05 04 2001 --------------------------------------- -- -- ---- Annuitant's signature (if applicable) month day year and date X --------------------------------------- -- -- ---- Co-annuitant's signature (if applicable) month day year and date /s/ Anytown, N.Y. --------------------------------------- Signed at (city, state) - -------------------------------------------------------------------------------- ORD 99669 New York -- Third Party Ed. 5/2001 Third Party Page 5 of 6 14 FINANCIAL Commission Option (Choose only one.): PROFESSIONAL'S 1. [ ]No Trail 2. [ ]Mid Trail SIGNATURE(S) 3. [ ]High Trail 4. [ ]Levelized Note: If an option is not selected, the default option will be Option 3. This application is submitted in the belief that the purchase of this contract is appropriate for the applicant based on the information provided and as reviewed with the applicant. Reasonable inquiry has been made of the owner concerning the owner's overall financial situation, needs, and investment objectives. The financial professional hereby certifies that all information contained in this application is true to the best of his or her knowledge. RICHARD ROE 1 2 3 4 5 6 7 8 9 ----------------------------------- - - - - - - - - - Financial professional's name Firm FA contract number (Please print) 9 8 7 6 5 4 3 2 1 - - - - - - - - - Prudential contract number X /s/ Richard Roe 05 04 2001 ----------------------------------- -- -- ---- Financial professional's month day year signature and date ----------------------------------- - - - - - - - - - Second financial professional's Firm FA contract number name(Please print) - - - - - - - - - Prudential contract number X ----------------------------------- -- -- ---- Second financial professional's month day year signature and date Sunnytown - SNTN 8 8 8 5 5 5 - 5 5 5 5 ---------------------------------- - - - - - - - - - - Branch name and code Financial professional's telephone number - -------------------------------------------------------------------------------- 15 ADDITIONAL REMARKS ----------------------------------------------------------- ----------------------------------------------------------- ----------------------------------------------------------- ----------------------------------------------------------- ----------------------------------------------------------- ----------------------------------------------------------- - -------------------------------------------------------------------------------- STANDARD PRUDENTIAL ANNUITY SERVICE CENTER MAIL TO: THIRD PARTY PO BOX 8210 PHILADELPHIA, PA 19101 OVERNIGHT PRUDENTIAL ANNUITY SERVICE CENTER MAIL TO: THIRD PARTY 2101 WELSH ROAD DRESHER, PA 19025 If you have any questions, please call the Prudential Annuity Service Center at (888) 778-5970 for customers, or (888) 778-5471 for financial professionals, Monday through Friday between 8:00 a.m. and 8:00 p.m. Eastern time. - -------------------------------------------------------------------------------- ORD 99669 NEW YORK - THIRD PARTY Ed. 5/2001 THIRD PARTY Page 6 of 6 NY MEMORANDUM DESCRIBING THE VARIABLE MATERIAL CONTAINED IN APPLICATION FORM ORD 99669-NEW YORK AND ORD 99669-NEW YORK-THIRD PARTY SECTION 7. PURCHASE PAYMENT ALLOCATION The allocation options have been bracketed to indicate that they are illustrative, i.e., we may rename, add to, delete from, or substitute other allocation options for those shown in the application.