Annuities Service Center P.O. Box 7960 Philadelphia, PA 19176 Tel 800.513.0805 Fax 800.207.7806 Pruco Life Insurance Company Of New Jersey www.prudential.com Overnight, Certified, Registered Delivery: SM Annuities Service Center MyRock Advisor Variable Annuity-New York 2101 Welsh Road Dresher, PA 19025 1. OWNERSHIP INFORMATION A. TYPE OF OWNERSHIP - Select One Natural Person(s) UGMA/UTMA Custodian Trust - (If selecting a Trust, submit the Certificate of Entity Ownership for Trusts form with this application.) B. OWNER U.S. Citizen Resident Alien/Citizen of: Male Female Social Security Number (all 9 digits required) or Tax ID Date of birth (mm/dd/yyyy) Name (First, Middle, Last, Suffix, Trust or Custodian) Street address City State Zip Home phone Mobile phone Email address C. JOINT OWNER - Not available if Owner is a Custodian, Trust or for Qualified Annuities. Joint Owner must be a natural person. Check here to designate the Joint Owners as each other’s Primary Beneficiary. U.S. Citizen Resident Alien/Citizen of: Male Female Social Security Number (all 9 digits required) Date of birth (mm/dd/yyyy) Address Same as Owner Name (First, Middle, Last, Suffix) Street address City State Zip Home phone Relationship to Owner D. ANNUITANT - Complete this Section if the Annuitant is different from the Owner or if the Owner is a Custodian or Trust. U.S. Citizen Resident Alien/Citizen of: Male Female Social Security Number (all 9 digits required) Date of birth (mm/dd/yyyy) Address Same as Owner Name (First, Middle, Last, Suffix) Street address City State Zip Home phone Mobile phone Email address P-VA-APP(11/20)-NY Page 1 of 8 ORD 310098 NY (All pages must be returned)

1. OWNERSHIP INFORMATION (continued) E. OPTIONAL OTHER ANNUITANT For Custodial IRA contracts your Optional Other Annuitant will be set up as a Contingent Annuitant. For Non-Qualified contracts your Optional Other Annuitant will be set up as a Joint Annuitant. U.S. Citizen Resident Alien/Citizen of: Male Female Social Security Number (all 9 digits required) Date of birth (mm/dd/yyyy) Address Same as Owner Name (First, Middle, Last, Suffix) Street address City State Zip Home phone Relationship to Owner 2. BENEFICIARY INFORMATION • Select Primary or Contingent Beneficiary type for each beneficiary. The beneficiary type will be Primary if not selected. • Percentage for all Primary Beneficiaries must total 100%. Percentage for all Contingent Beneficiaries must total 100%. • For more than 3 beneficiaries, use section 5 to provide all information requested below for each beneficiary. • For Custodial IRA contracts, the Custodian must be listed as the sole Primary Beneficiary. Primary Contingent Social Security Number (all 9 digits required) or Tax ID Date of birth (mm/dd/yyyy) % Name (First, Middle, Last, Suffix, Trust or Custodian) Relationship Percentage Home phone Street address City State Zip TRUSTEE NAME AND DATE OF TRUST REQUIRED ONLY IF A TRUST IS LISTED AS BENEFICIARY Trustee Name Date of Trust (mm/dd/yyyy) Primary Contingent Social Security Number (all 9 digits required) Date of birth (mm/dd/yyyy) % Name (First, Middle, Last, Suffix, Trust or Custodian) Relationship Percentage Home phone Street address City State Zip Primary Contingent Social Security Number (all 9 digits required) Date of birth (mm/dd/yyyy) % Name (First, Middle, Last, Suffix, Trust or Custodian) Relationship Percentage Home phone Street address City State Zip P-VA-APP(11/20)-NY Page 2 of 8 ORD 310098 NY (All pages must be returned)

3. ANNUITY INFORMATION A. TYPE OF CONTRACT TO BE ISSUED Non-Qualified IRA Roth IRA B. PREMIUM(S) - Must total at least $10,000 Source of Funds Payment Type Expected Company Name Account Number Qualified Non-Qualified Amount (if applicable) (if applicable) Funds Enclosed w/ App Transfer 1035 Exchange Transfer/Exchange Form Direct Rollover Contribution $ Provided Rollover Owner Requesting Funds Contribution Tax Year1 _______ Funds Enclosed w/ App Transfer 1035 Exchange Transfer/Exchange Form Direct Rollover Contribution $ Provided Rollover Owner Requesting Funds Contribution Tax Year1 _______ Funds Enclosed w/ App Transfer 1035 Exchange Transfer/Exchange Form Direct Rollover Contribution $ Provided Rollover Owner Requesting Funds Contribution Tax Year1 _______ Total Expected Amount $ 1If no year is indicated, contribution defaults to current tax year. Contributions cannot be attributed to the previous tax year after the annual Internal Revenue Service (IRS) tax deadline. C. EXISTING COVERAGE AND REPLACEMENT QUESTIONS Owner Financial Required: Both the Owner Response and the Financial Professional Response columns must Response Professional be completed. Response Does the Owner have any existing individual life insurance policies or annuity contracts? YES NO YES NO (If yes, complete and submit the required Regulation 60 paperwork) Will this annuity replace or change any existing individual life insurance YES NO YES NO policies or annuity contracts? OPTIONAL BENEFITS Optional Death Benefit: Return of Premium Death Benefit P-VA-APP(11/20)-NY Page 3 of 8 ORD 310098 NY (All pages must be returned)

4. INVESTMENT SELECTION - NOTE: ALL ELECTIONS MUST BE IN WHOLE PERCENTAGES, NOT DOLLARS A. AUTOMATIC REBALANCING Check here if you would like the below percentages to rebalance. Indicate the day of the month and frequency. Day of the Month (1st - 28th) ______ Rebalancing Frequency: Monthly Quarterly Semi-Annually Annually We will not automatically rebalance your variable Account Value to stay consistent with the original allocation unless you specifically direct us to do so in the Automatic Rebalancing section above. You and your Financial Professional are responsible for determining which Sub-account(s) are best for you. B. INVESTMENT OPTIONS Prudential assesses a Fund Access Charge on Account Value invested in certain Investment Options. Please see the product prospectus for the list of Investment Options to which the Fund Access Charge applies. EQUITY Large-Cap Growth American Funds Insurance Series® Growth Fund - Class 1 Large-Cap Value BlackRock Capital Appreciation V.I. Fund - Class I BlackRock Basic Value V.I. Fund - Class I BlackRock Large Cap Focus Growth V.I. Fund - Class I BlackRock Equity Dividend V.I. Fund - Class I ClearBridge Variable Aggressive Growth Portfolio - Class I ClearBridge Variable Dividend Strategy Portfolio - Class I ClearBridge Variable Large Cap Growth Portfolio - Class I MFS® Value Series - Initial Class Fidelity® Variable Insurance Products Contrafund℠ Portfolio - PSF Value Portfolio - Class I Initial Class Vanguard Variable Insurance Fund Equity Income Portfolio Fidelity® Variable Insurance Products Growth Opportunities Portfolio - Initial Class Vanguard Variable Insurance Fund Diversified Value Portfolio Fidelity® Variable Insurance Products Growth Portfolio - Initial Class VA U.S. Large Value Portfolio MFS® Growth Series - Initial Class Mid-Cap Growth MFS® Massachusetts Investors Growth Stock Portfolio - Initial Class MFS® Mid Cap Growth Series Initial Class PSF Jennison Portfolio - Class I PSF SP Prudential U.S. Emerging Growth Portfolio - Class I Vanguard Variable Insurance Fund Capital Growth Portfolio Mid-Cap Blend Vanguard Variable Insurance Fund Growth Portfolio ClearBridge Variable Mid Cap Portfolio - Class I Large-Cap Blend Fidelity® Variable Insurance Products Mid Cap Portfolio - Initial Class American Funds Insurance Series® Blue Chip Income and Growth Fund - Vanguard Variable Insurance Fund Mid-Cap Index Portfolio Class 1 Small-Cap Growth American Funds Insurance Series® Growth-Income Fund - Class 1 ClearBridge Variable Small Cap Growth Portfolio - Class I BlackRock Advantage Large Cap Core V.I. Fund - Class I MFS® New Discovery Series - Initial Class ClearBridge Variable Appreciation Portfolio - Class I Small-Cap Blend MFS® Investors Trust Series - Initial Class Fidelity® Variable Insurance Products Disciplined Small Cap Portfolio - MFS® Research Series - Initial Class Initial Class PSF Equity Portfolio - Class I PSF Small Capitalization Stock Portfolio - Class I PSF Jennison 20/20 Focus Portfolio - Class I Small-Cap Value PSF Stock Index Portfolio - Class I PSF SP Small-Cap Value Portfolio - Class I Vanguard Variable Insurance Fund Equity Index Portfolio VA U.S. Targeted Value Portfolio Vanguard Variable Insurance Fund Total Stock Market Index Portfolio P-VA-APP(11/20)-NY Page 4 of 8 ORD 310098 NY (All pages must be returned)

4. INVESTMENT SELECTION - NOTE: ALL ELECTIONS MUST BE IN WHOLE PERCENTAGES, NOT DOLLARS (continued) International Developed Markets PSF Government Income Portfolio - Class I Fidelity® Variable Insurance Products International Capital Vanguard Variable Insurance Fund Total Bond Market Index Portfolio Appreciation Portfolio - Initial Class Western Asset Core Plus VIT Portfolio - Class I MFS® International Intrinsic Value Portfolio - Initial Class High Yield PSF Global Portfolio - Class I Fidelity® Variable Insurance Products High Income Portfolio - Initial Class VA International Small Portfolio PSF High Yield Bond Portfolio - Class I VA International Value Portfolio Vanguard Variable Insurance Fund High Yield Bond Portfolio Vanguard Variable Insurance Fund International Portfolio Western Asset Variable Global High Yield Bond Portfolio - Class I Vanguard Variable Insurance Fund Total International Stock Market Global Fixed Income Index Portfolio VA Global Bond Portfolio International Emerging Markets Vanguard Variable Insurance Fund Global Bond Index Portfolio Fidelity® Variable Insurance Products Emerging Markets Portfolio - Initial Class Money Market Sector Exposure PSF Government Money Market Portfolio - Class I Fidelity® Variable Insurance Products Consumer Discretionary Portfolio - Short Term Initial Class American Funds Insurance Series® Ultra-Short Bond Fund - Class 1 Fidelity® Variable Insurance Products Financial Services Portfolio - Initial Class Vanguard Variable Insurance Fund Short-Term Investment-Grade Portfolio Fidelity® Variable Insurance Products Health Care Portfolio - Initial Class VA Short-Term Fixed Portfolio Floating Rate Fidelity® Variable Insurance Products Industrials Portfolio - Initial Class Fidelity® Variable Insurance Products Floating Rate High Income Portfolio Fidelity® Variable Insurance Products Technology Portfolio - Initial Class - Initial Class Fidelity® Variable Insurance Products Utilities Portfolio - Initial Class Unconstrained MFS® Technology Portfolio - Initial Class Fidelity® Variable Insurance Products Strategic Income Portfolio - MFS® Utilities Series - Initial Class Initial Class ASSET ALLOCATION PSF Natural Resources Portfolio - Class I American Funds Insurance Series® Asset Allocation Fund - Class 1 Vanguard Variable Insurance Fund Real Estate Index Portfolio BlackRock Global Allocation V.I. Fund - Class I FIXED INCOME Domestic Fidelity® Variable Insurance Products Balanced Portfolio - Initial Class AST BlackRock Corporate Bond Portfolio MFS® Total Return Series - Initial Class AST PIMCO Corporate Bond Portfolio PSF Conservative Balanced Portfolio - Class I AST Prudential Corporate Bond Portfolio PSF Flexible Managed Portfolio - Class I AST T. Rowe Price Corporate Bond Portfolio QS Variable Conservative Growth - Class I AST Western Asset Corporate Bond Portfolio QS Variable Growth Portfolio - Class I American Funds Insurance Series® Bond Fund - Class 1 QS Variable Moderate Growth - Class I American Funds Insurance Series® U.S. Government/AAA-Rated VA Global Moderate Allocation Portfolio Securities Fund - Class 1 Vanguard Variable Insurance Fund Balanced Portfolio Fidelity® Variable Insurance Products Investment Grade Bond Portfolio - Initial Class Vanguard Variable Insurance Fund Conservative Allocation Portfolio MFS® Total Return Bond Series - Initial Class Vanguard Variable Insurance Fund Moderate Allocation Portfolio PSF Diversified Bond Portfolio - Class I Total % P-VA-APP(11/20)-NY Page 5 of 8 ORD 310098 NY (All pages must be returned)

5. ADDITIONAL INFORMATION If needed for: • Beneficiaries (include Beneficiary’s full social security number, name, date of birth, relationship to the owner, the Beneficiary type (Primary or Contingent) and the applicable percentage.) • Interested Parties (include name, social security number, date of birth and address.) • Special Instructions 6. IMPORTANT NOTICES, OWNER ACKNOWLEDGEMENTS AND SIGNATURE(S) To help the government fight the funding of terrorism and money laundering activities, federal law requires all financial institutions, including insurance companies, to obtain, verify, and record information that identifies each person who opens an account, including an application for an annuity contract. When you apply for an annuity contract, we ask for your name, address, date of birth, and other information that will allow us to identify you. We may also ask to see identifying documents. By signing below, I acknowledge that I have read, understand, and agree to the following statements: • I represent that the Annuity for which I am applying is not being purchased for speculation, arbitrage, viatication or any other type of collective investment scheme now or at any time prior to its termination; and • I acknowledge that the Annuity for which I am applying may not be traded on any stock exchange or secondary market; and • I represent that I am not being compensated in any way for the purchase of the Annuity for which I am applying; and • I understand that if I have purchased another Non-Qualified Annuity from Pruco Life Insurance Company of New Jersey or an affiliated company this calendar year that they will be considered as one annuity for tax purposes. If I take a distribution from any of these contracts, the taxable amount of the distribution will be reported to me and the IRS based on the earnings in all such contracts purchased during this calendar year; and • This variable annuity is suitable for my investment time horizon, goals and objectives and financial situation and needs; and • I understand that annuity payments, benefits or surrender values, when based on the investment experience of the separate account investment options, are variable and not guaranteed as to a dollar amount; and • Pruco Life Insurance Company of New Jersey may limit, restrict, suspend or reject additional Purchase Payments in the future in order to manage financial risk based on market and/or economic conditions; and • I represent to the best of my knowledge and belief that the statements made in this application are true and complete; and • I acknowledge that I have received a current prospectus for this annuity; and • I understand and acknowledge that the investment advisory services provided to me in connection with this Annuity are not provided by Pruco Life Insurance Company of New Jersey or Prudential Annuity Distributors, Inc. (“PAD”) and neither Pruco Life Insurance Company nor PAD are responsible for, and will not be liable to me for, such investment advisory services; and • I understand that any investment advisory fee I will pay for advisory services is in addition to and separate from the fees and expenses of this Annuity. P-VA-APP(11/20)-NY Page 6 of 8 ORD 310098 NY (All pages must be returned)

6. IMPORTANT NOTICES, OWNER ACKNOWLEDGEMENTS AND SIGNATURE(S) (continued) REQUIRED: State where this application was signed (If application is signed in a State other than the Owner’s State of Residence, a Contract Situs Form is required.) OWNER’S TAX CERTIFICATION (Substitute Form W-9) - To be completed only by U.S. persons (including U.S. citizens and resident aliens). If not a U.S. person, you are required to submit the applicable IRS Form W-8 series. Under penalties of perjury, I certify that the taxpayer identification number listed on this form is my correct SSN/EIN and I am a U.S. citizen or other U.S. person (including resident aliens). I further certify that I am exempt from backup withhold- ing and/or FATCA reporting unless I check the applicable box(es) below: I have been notified by the Internal Revenue Service that I am subject to backup withholding due to the failure to report all interest or dividends. Prudential is required to withhold income tax on any payments which include interest and dividends when the owner is subject to backup withholding. I am subject to the reporting requirements of the Foreign Account Tax Compliance Act (FATCA). The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding. SIGN HERE Owner Signature (or trustee or custodian, if applicable) Date of Signature (mm/dd/yyyy) TITLE (if any) If signing on behalf of a custodian, you must indicate your official title / position with the entity; if signing as a Trustee for a Trust, please provide the Trustee designation. SIGN HERE Joint Owner Signature Date of Signature (mm/dd/yyyy) SIGN HERE Annuitant Signature (if different from Owner) Date of Signature (mm/dd/yyyy) SIGN HERE Joint / Contingent Annuitant Signature Date of Signature (mm/dd/yyyy) P-VA-APP(11/20)-NY Page 7 of 8 ORD 310098 NY (All pages must be returned)

7. FINANCIAL PROFESSIONAL ACKNOWLEDGEMENTS AND SIGNATURE(S) FINANCIAL PROFESSIONAL STATEMENT I am authorized and/or appointed to sell this variable annuity. I have reviewed the training materials provided by Prudential. I have fully discussed and explained the variable annuity features and charges including restrictions to the Owner. I believe this variable annuity is suitable given the Owner’s investment time horizon, goals and objectives, and financial situation and needs. I represent that: (a) I have delivered current applicable prospectuses and any supplements for the variable annuity (which includes summary descriptions of the underlying investment options); and (b) have used only current Pruco Life approved sales material. I certify that I have truly and accurately recorded on this application the information provided by the applicant. I acknowledge that Pruco Life and its affiliates will rely on this statement. SIGN HERE Financial Professional Signature Date of Signature (mm/dd/yyyy) SIGN HERE Financial Professional Signature Date of Signature (mm/dd/yyyy) A. FINANCIAL PROFESSIONAL(S) USE ONLY Name (First, Middle, Last ) Percentage % ID Number Telephone Number Email address Name (First, Middle, Last ) Percentage % ID Number Telephone Number Email address B. BROKER/DEALER USE ONLY Name: FOR BROKER/DEALER USE ONLY Networking No. Annuity No. (If established) P-VA-APP(11/20)-NY Page 8 of 8 ORD 310098 NY (All pages must be returned)