Allianz Life Insurance Company
of North America
[Allianz VisionSM] Variable Annuity Application
					[DA____________________]
1.   Account registration
Ownership is   ■  Individual	■  Qualified plan		■  Custodian		■  Trust (Include the date of trust in the name.)
■  Charitable Trust		■  Other__________
Owner
Individual Owner first name				MI		Last name	Jr., Sr., III

[Missing Graphic Reference]

Non-individual owner name (Attach Non- Individual Ownership form or Qualified Plan Acknowledgement form if applicable.)

Social Security Number or Tax ID Number

Mailing address

City

State

ZIP code

Telephone number

Gender

■  Male

Date of birth (mm/dd/yyyy)

Are you a non-resident alien?

■  Female

■  Yes  (Attach W8 BEN)   ■  No

Joint Owner

First name

MI

Last name

Jr., Sr., III

Mailing address

City

State

ZIP code

Telephone number

Gender

Date of birth (mm/dd/yyyy)

Are you a non-resident alien?

■  Male

■  Female

■  Yes  (Attach W8 BEN)   ■  No

Relationship to Owner

Social Security Number

Annuitant (Complete if different from Owner.)

First name

MI

Last name

Jr., Sr., III

Mailing address

City

State

ZIP code

Telephone number

Street address (required if a P.O. Box was used for mailing address)

City

State

ZIP code

Gender

Social Security Number

Date of birth (mm/dd/yyyy)

Are you a non-resident alien?

■  Male

■  Female

■  Yes  (Attach W8 BEN)   ■  No

[Missing Graphic Reference]

F60000                                                                     Page 1 of [7]                                                                           (5/2011)

2.   Purchase Payment (This section must be completed.

Make check payable to Allianz.)

Source of purchase payment. Complete all that apply.

■	Nonqualified	Account Type(s) at prior carrier:_________________(e.g. 40sB, IRA, 401K, Etc.)
■	Qualified
■	Purchase Payment enclosed with application. (Include replacement forms if required)
	Amount enclosed: $__________
■	This Contract will be funded by a 1035 exchange, tax qualified transfer/rollover, CD transfer, or mutual fund redemption. (Include replacement/ transfer forms if required.)
	Expected amount: $__________
■	This Contract will be funded by funds not requested or facilitated by Allianz. (Include replacement forms if required.)
	Expected amount: $__________

3.   Plan specifics (This section must be completed to indicate how this Contract should be issued.

Nonqualified:■		Qualified IRA:	■   IRA	■   Roth IRA	■   SEP IRA   ■   Roth conversion	(Contribution for tax year __________)
		Qualified plans:  ■401		■   401 one person defined benefit
4.	Telephone authorization
■  Yes  By checking "yes," I am authorizing and directing Allianz to act on telephone or electronic instructions from the Registered
	Representative and/or anyone authorized by him/her to transfer Contract Values among the Investment Options. If the box is not
	checked, this authorization will be permitted for the Owner only. Allianz will use reasonable procedures to confirm that
	these instructions are authorized as genuine. As long as these procedures are followed, Allianz and its affiliates and their directors,
	trustees, officers, employees, representatives, and/or agents will be held harmless for any claim, liability, loss, or cost.
	The electronic transaction privilege may be modified or terminated at the discretion of the company.
5.   Replacement (This section must be completed.)
Do you have existing life insurance or annuity contracts? . . . . .					. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .	■  Yes	■  No
Will the annuity contract applied for replace or change existing contracts or policies?    . . . . .						■  Yes	■  No

If there is existing coverage, states that have adopted the NAIC Model Replacement Regulation or a variation of the Model, require that the replacement form be completed even if a replacement is not indicated. For a replacement in any state, attach theappropriate replacement form for the state in which the application is taken. The Registered Representative must also complete the Registered Representative section regarding replacement.

[6.  Contract options - Must select only one]

■   Base Contract (No additional cost)

■   Bonus Option1

■   Short Withdrawal Charge Option1

■   No Withdrawal Charge Option1

[7.  Optional death benefit]

■   Quarterly Value Death Benefit1

[1 Carries an additional charge]

F60000                                                                        Page 2 of [7]                                                                           (5/2011)

[8.  Other benefits - Must select only one]

■   No Additional Benefit (No additional cost)

■   Investment Protector1

Number of years to the initial Target Value Date ______

■   Investment Plus1(Complete Covered Person(s) information below.)

Number of years to the initial Protected Investment Date ______

■   Income Protector1(Complete Covered Person(s) information below.)

Covered Person(s) - Select one.

■    Single Lifetime Plus Payments or Lifetime Income Payments:

Name   __________________________________________________________________________________

This person is: (check one)	■  Owner		■  Joint Owner■  Annuitant, if owned by a non-individual
Date of birth ____/____/____		Gender:	■  Male	■  Female

Proof of age is required for all Covered Person(s). Identification must be a legible copy of a government recognizedidentification that includes the Covered Person(s) date of birth. Select the form of identification that is being submitted.

■   Driver's license    ■   Certificate of birth    ■   Passport    ■   Other _______________________________

OR

■   Joint Lifetime Plus Payments or Lifetime Income Payments:

First Covered Person's name__________________________________________________________________

Date of birth ____/____/____     Gender:     ■  Male     ■  Female

Proof of age is required for all Covered Person(s). Identification must be a legible copy of a government recognizedidentification that includes the Covered Person(s) date of birth. Select the form of identification that is being submitted.

■   Driver's license    ■   Certificate of birth    ■   Passport    ■   Other _______________________________

This person is: (check one)■  Owner

■   Joint Owner

■   Annuitant, if owned by a non-individual

■   Sole primary Beneficiary (qualified or non-individual, nonqualified)

■   Sole contingent Beneficiary (401 qualified plan, custodial IRA)

Second Covered Person's name _______________________________________________________________

Date of birth ____/____/____     Gender:     ■  Male     ■  Female

Proof of age is required for all Covered Person(s). Identification must be a legible copy of a government recognizedidentification that includes the Covered Person(s) date of birth. Select the form of identification that is being submitted.

■   Driver's license    ■   Certificate of birth    ■   Passport    ■   Other _______________________________

This person is: (check one)■  Owner

■   Joint Owner

■   Annuitant, if owned by a non-individual

■   Sole primary Beneficiary (qualified or non-individual, nonqualified)

■   Sole contingent Beneficiary (401 qualified plan, custodial IRA)

By selecting the [Income Protector, Investment Protector, or Investment Plus], I acknowledge that my selections of Investment Options are restricted and that Allianz will reallocate my Contract Value in accordance with the asset allocation and transfer provisions in the Contract.

[1 Carries an additional charge]

F60000                                                                        Page 3 of [7]                                                                           (5/2011)

[9.]   Dollar cost averaging (Optional)

•   Select a 6 month or 12 month DCA program only if you wish to participate in dollar cost averaging.

•   100% of your initial Purchase Payment will be applied to the DCA Money Market Account.

•   Your selections in the Investment Options section need to meet any restrictions for the benefit selected.

 ■ 6 month ■ 12 month

[10.]   Investment Option allocations

You may select up to [15] Investment Options. You must make allocations in whole percentages (e.g. 33.3% or dollars are not permitted). Please see the current prospectus for Investment Option requirements.

[Income Protector or Investment Plus]

Group C Investment Options

Fund of Funds

____% AZL FusionSM Moderate Fund

____% AZL FusionSM Balanced Fund

____% AZL ConservativeSM Balanced Fund

____% AZL® Growth Index Strategy Fund

____% AZL® Balanced Index Strategy Fund

____% Fidelity VIP FundsManager 50% Portfolio

____% Fidelity VIP FundsManager 60% Portfolio

High Yield Bonds

____% Franklin High Income Securities Fund

____% PIMCO VIT High Yield Portfolio

Intermediate-Term Bonds

____% PIMCO VIT Emerging Markets Bond Portfolio

____% PIMCO VIT Global Bond Portfolio (Unhedged)

____% PIMCO VIT Real Return Portfolio

____% PIMCO VIT Total Return Portfolio

____% Templeton Global Income Securities Fund

____% Franklin U.S. Government Fund

Cash Equivalent

____% AZL® Money Market Fund

Specialty

____% AZL® Van Kampen Equity and Income Fund

____% PIMCO VIT All Asset Portfolio

____% PIMCO VIT Global Multi-Asset Portfolio

____% BlackRock Global Allocation V.I. Fund

____% AZL® Franklin Templeton Founding Strategy Plus Fund

____% AZL® Gateway Fund

Total of _______% (must equal 100%)

F60000                                                                        Page 4 of [7]                                                                           (5/2011)

[10.]     Investment Option allocations (Continued)

You may select up to [15] Investment Options. You must make allocations in whole percentages (e.g. 33.3% or dollars are not permitted). Please see the current prospectus for Investment Option requirements.

[Investment Protector or No Additional Benefit]

Group A Investment Options
Small Cap	Specialty
____% AZL® Columbia Small Cap Value Fund	____% AZL® Schroder Emerging Markets Equity Fund
____% AZL® Franklin Small Cap Value Fund	____% AZL® Morgan Stanley Global Real Estate Fund
____% AZL® Turner Quantitative Small Cap Growth Fund	____% PIMCO VIT Commodity RealReturn Strategy Portfolio
____% AZL® Allianz AGIC Opportunity Fund	____% Franklin Income Securities Fund
____% AZL® Small Cap Stock Index Fund	_____% Franklin Templeton VIP Founding Funds Allocation Fund
	Fund of Funds
	____% AZL FusionSM Growth Fund
Group B Investment Options
Mid Cap	International Equity (continued)
____% AZL® Columbia Mid Cap Value Fund	____% Templeton Growth Securities Fund
____% AZL®  Morgan Stanley Mid Cap Growth Fund	____% PIMCO EqS Pathfinder Portfolio
____% Mid Cap Index Fund	Large Blend
Large Growth	____% AZL®  MFS Investors Trust Fund
____% AZL®  Dreyfus Equity Growth Fund	____% AZL®  J.P. Morgan U.S. Equity Fund
____% AZL®  BlackRock Capital Appreciation Fund	____% AZL®  S&P 500®  Index Fund
International Equity	Large Value
____% AZL®  Invesco International Equity Fund	____% AZL®  Davis NY Venture Fund
____% AZL®  International Fund	____% AZL®  Eaton Vance Large Cap Value Fund
____% AZL®  Morgan Stanley International Equity Fund	____% AZL®  Van Kampen Growth and Income Fund
	____% Mutual Shares Securities Fund
Group X Investment Options
Fund of Funds	Specialty
____% AZL FusionSM Moderate Fund	____% AZL® Van Kampen Equity and Income Fund
____% AZL FusionSM Balanced Fund	____% BlackRock Global Allocation V.I. Fund
____% AZL FusionSM Conservative Fund	____% PIMCO VIT All Asset Portfolio
____% AZL®  Growth Index Strategy Fund	____% PIMCO VIT Global Multi-Asset Portfolio
____% AZL®  Balanced Index Strategy Fund	____% AZL® Franklin Templeton Founding Strategy Plus Fund
____% Fidelity VIP FundsManager 50% Portfolio	____% AZL® Gateway Fund
____% Fidelity VIP FundsManager 60% Portfolio
Group Y Investment Options
High-Yield Bonds	Intermediate-Term Bonds (continued)
____% Franklin High Income Securities Fund	____% Franklin U.S. Government Fund
____% PIMCO VIT High Yield Portfolio	____% PIMCO VIT Total Return Portfolio
Intermediate-Term Bonds	____% Templeton Global Bond Securities Fund
____% PIMCO VIT Emerging Markets Bond Portfolio	Cash Equivalent
____% PIMCO VIT Global Bond Portfolio (Unhedged)	____% AZL® Money Market Fund
____% PIMCO VIT Real Return Portfolio

Total of _______% (must equal 100%)

F60000                                                                        Page 5 of [7]                                                                           (5/2011)

[11.]     Beneficiary designation (If you need additional space, attach a complete list signed by Owner(s).)

■  Primary				Percentage			Social Security Number or Tax ID Number
■  Contingent
First name							MI	Last name
Relationship
■  Primary			Percentage			Social Security Number or Tax ID Number
■  Contingent
First name						MI		Last name
Relationship
■  Primary		Percentage			Social Security Number or Tax ID Number
■  Contingent
First name					MI			Last name
Relationship
Non-individual Beneficiary information
If the Beneficiary is a qualified plan, custodian, trust, charitable trust or other non-individual please check the applicable
box and include the name above.
■ Qualified plan	■ Custodian  ■ Trust (Include the date of trust in the name.)								■ Charitable Trust	■ Other_______________
■  Primary				Percentage	Social Security Number or Tax ID Number
■  Contingent

[12.]     Registered Representative

By signing below, the Registered Representative certifies to the following:

I am FINRA registered and state licensed for variable annuity contracts in all required jurisdictions; and I provided the Owner(s) with the most current prospectus. To the best of my knowledge, the applicant: ■ DOES ■ DOES NOT have existing life insurance policies or annuity contracts. To the best of my knowledge and belief, this application ■ DOES ■ DOES NOT involve replacement of existing life insurance or annuities. If this is a replacement, include a copy of each disclosure statement and a list of companies involved.

Registered Representative’s signature	B/D Rep. ID
Registered Representative’s first and last name (please print)		Percent split
Registered Representative’s signature (split case)	B/D Rep. ID
Registered Representative’s first and last name (please print) (split case)		Percent split
Registered Representative’s signature (split case)	B/D Rep. ID
Registered Representative’s first and last name (please print) (split case)		Percent split
Registered Representative’s address	Registered Representative’s telephone number
Broker/dealer name (please print)
Authorized signature broker/dealer (if required)

Commission options (please check one)

■   A          ■   B           ■   C

F60000                                                                        Page 6 of [7]                                                                           (5/2011)

[13.]     Statement of applicant

The following states require applicants to read and acknowledge the statement for your state below.

Arkansas, District of Columbia, and Massachusetts: Any person who knowinglypresents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies.

Kentucky, Maine, New Mexico, Ohio, Tennessee, and West Virginia: Any person who knowingly, and with intent to defraud any insurance company, submits an application or files a statement of claim containing any false, incomplete, or misleading information, commits a fraudulent insurance act, which is a crime, and may be subject to criminal prosecution and civil penalties. In ME and TN, additional penalties may include imprisonment, fines, or denial of insurance benefits.

Louisiana: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

Oklahoma: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

Rhode Island: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

By signing below, the Owner acknowledges the applicable statements mentioned above and agrees to the following:

I received a prospectus and have determined that the variable annuity applied for is not unsuitable for my investment objectives, financial situation, and financial needs. It is a long-term commitment to meet my financial needs and goals. I understand that the Contract

Value and variable Annuity Payments may increase or decrease depending on the investment results of the variable Investment Options, and that under the Base Contract there is no guaranteed minimum Contract Value or variable Annuity Payment. If I selected any additional options, any guarantees provided for those options are outlined in my Contract and prospectus. To the best of my knowledge and belief, all statements and answers in this application are complete and true. It is furtheragreed that these statements and answers will become a part of any Contract to be issued. No representative is authorized to modify this agreement or waive any Allianz rights or requirements.

For information on current benefit features, restrictions or charges please review with your Registered Representative.

■ Please send me a statement of additional information (Also available on the [SEC Web site, http://www.sec.gov])

Owner/Trustee/Authorized signer signature	Joint Owner/Trustee/Authorized signer signature
Signed at (City, State)	Date signed

[14.]     Home office use only

If Allianz Life Insurance Company of North America makes a change in this space in order to correct any apparent errors or omissions, it will be approved by acceptance of this Contract by the Owner(s); however, any material change must be accepted in writing by the Owner(s). Changes to this application that affect product, benefits, amount of insurance, or age require acceptance by Owner(s).

Please call Allianz with any questions at [800.624.0197].

		Mailing information
	Applications that HAVE a check attached
Regular mail		Overnight, certified, or registered
Allianz		Wells Fargo LBX Services
NW 5989		NW 5989 Allianz
PO Box 1450		1350 Energy Lane, Ste. 200
Minneapolis, MN 55485-5989		St. Paul, MN 55108-5254
	Applications that DO NOT HAVE a check attached
Regular mail		Overnight, certified, or registered
Allianz		Allianz
PO Box 561		5701 Golden Hills Drive
Minneapolis, MN 55440-0561		Golden Valley, MN 55416-1297

F60000                                                                        Page 7 of [7]                                                                            (5/2011)