Document:

Allianz Index Advantage NFSM Variable Annuity Application[Contract number
          ]                                      Individual Owner first name  MI  Last name  Jr., Sr., III    Mailing address      Email address    City  State  ZIP code    Home telephone number          1. Annuity Registration  Ownership is [
          Individual/Joint Qualified plan Custodian Trust (Include the date of the trust in the name.) UTMA/UGMA Other ]OwnerNon-individual owner name (Attach Non-Individual Ownership Form or Qualified Plan Acknowledgement Form if applicable.)Social
          Security Number/TIN  Street address (required if a PO Box was used for mailing address)  City    State  ZIP code  Cell phone number  GenderMale Female  Date of birth (mm/dd/yyyy)    Are you a non-resident alien? Yes No(If yes, then you are not
          eligible for this product.)    Joint Owner  Annuitant (Complete if different from Owner.)  Street address (required if a PO Box was used for mailing address)  Relationship of Annuitant to Owner    Spouse under a legally recognized
          marriage    Other:                 First name  MI  Last name        Jr., Sr., III  Mailing address        Email address      City    State  ZIP code    Home telephone number    GenderMale Female  Date of birth (mm/dd/yyyy)    Are you a
          non-resident alien? Yes No(If yes, then you are not eligible for this product.)        Relationship to OwnerSpouse under a legally recognized marriage Other:         Social Security Number/TIN        First name  MI  Last name        Jr., Sr.,
          III  Mailing address        Email address      City    State  ZIP code    Home telephone number    Allianz Life Insurance Company of North America  IXA-APP-02-NF  1  [(4/2019)]  City      State  ZIP code    Cell phone number  GenderMale
          Female  Social Security Number/TIN  Date of birth (mm/dd/yyyy)      Are you a non-resident alien? Yes No(If yes, then you are not eligible for this product.)   

    

  

   

  
    
      

  

  
    
      

    

    
             2. Purchase Payment (This section must be completed.) Make check(s) payable to Allianz Life Insurance
          Company of North America (Allianz).    Include replacement forms if requiredMethod of Payment (Select all that apply)Purchase Payment enclosed with application.  Total amount enclosed: $   Plan type at prior financial institution or contribution
          instructions:                      Qualified Traditional IRA SEP IRAEmployer contribution to SEP IRAContribution to Traditional IRA for year Qualified Plan (401(a) plan)Other   Roth (Qualified)  Contribution to Roth IRA for year     Roth
          IRAInherited IRA (Qualified)Inherited IRA Inherited Roth IRANonqualifiedOther nonqualified payment        This Contract will be funded by money requested or facilitated by Allianz with transfer forms included.If 1035 exchange or tax-qualified
          transfer, complete the [Authorization to Transfer Funds form].Total expected amount: $ This Contract will be funded by money requested or facilitated by Allianz when transfer forms are received at a later date.If 1035 exchange or tax-qualified
          transfer, complete the [Authorization to Transfer Funds form].Total expected amount: $ This Contract will be funded by money not requested or facilitated by Allianz. Total expected amount: $ Plan type at prior financial institution or
          contribution instructions:                      Qualified Traditional IRA SEP IRAEmployer contribution to SEP IRAContribution to Traditional IRA for year Qualified Plan (401(a) plan)Other   Roth (Qualified)  Contribution to Roth IRA for year
              Roth IRAInherited IRA (Qualified)Inherited IRA Inherited Roth IRANonqualifiedOther nonqualified payment  3. Plan Specifics (This section must be completed to indicate how this Contract should be issued.)                Nonqualified: Qualified
          plans: IRA:Inherited IRA:  Nonqualified401(a) defined contribution plan  401(a) one person defined benefit plan    Traditional IRA Inherited IRA    SEP IRAInherited Roth IRA  Roth IRA  Roth IRA (conversion of existing
          IRA)                                      IXA-APP-02-NF  2  [(4/2019)] 

    

  

   

  
    
      

  

  
    
      

    

    
       5. Replacement (This section must be completed.)          Yes No Do you have existing life insurance
          policies or annuity contracts?Yes No Will the annuity contract applied for replace or change existing policies or contracts?Notice to Financial Professional: If the Owner does have existing life insurance policies or annuity contracts and the
          applicationis being written in an NAIC replacement model state, Allianz requires that you must present and read to the Owner the Replacement of Life Insurance or Annuity form and return the notice, signed by both the Financial Professional and
          Owner, with the Application. Replacement forms must be signed and dated on or before the application signed date.  6. Optional Death Benefit    [ Maximum Anniversary Value Death Benefit (Carries an additional charge)]  7. Index Effective Date
          (This section must be completed.)      The Index Effective Date can be any Business Day from the Issue Date up to and including the first Quarterly Contract Anniversary. However, it cannot be the 29th, 30th, or 31st of a month. If the Index
          Effective Date would occur on the 29th, 30th, or 31st of a month, or on a day that is not a Business Day, we change the Index Effective Date to be the next available Business Day.If the Index Effective Date is not the Issue Date, any portion of
          Purchase Payments allocated to the Index Option(s) will be placed in the [AZL® Government Money Market Fund] until the Index Effective Date.[ Earliest Index Effective Date – If chosen, the earliest Index Effective Date is the Issue Date of the
          Contract when the initial Purchase Payment, application, and requirements are received in good order. This option is not designed to accommodate multiple Purchase Payments (e.g., 1035 exchanges, tax qualified transfers/rollovers, etc.) expected
          before the first Quarterly Contract Anniversary.ORDeferred Index Effective Date – If chosen, the deferred Index Effective Date is the first Quarterly Contract Anniversary. You can change the Index Effective Date prior to the first Quarterly
          Contract Anniversary by contacting Allianz. This option is designed to accommodate multiple Purchase Payments expected before the first Quarterly Contract Anniversary.]  8. Allocation Options  Allocations must be in whole percentages (e.g., 33.3%
          or dollars are not permitted) which total 100%.If Purchase Payments are received before the Index Effective Date and you select an Index Option, the following will occur:Your Purchase Payments will be placed in the [AZL® Government Money Market
          Fund].Then, on the Index Effective Date we will rebalance your Contract Value among your selected Allocation Options below.If additional Purchase Payments are received after the Index Effective Date and you select an Index Option, then we will
          place the portion of your Purchase Payment you allocate to the Index Options in the [AZL® Government Money Market Fund] until the next Index Anniversary.We only allow allocations (both Purchase Payments and transfers of Contract Value) into the
          Index Options on the Index Effective Date and on subsequent Index Anniversaries.We only allow transfers of Index Option Value from the Index Options to the Variable Options on every [sixth Index Anniversary].Please see the current prospectus for
          allocation requirements.[(continued on next page)]  4. Electronic Authorization      Yes Electronic Authorization – Allianz accepts allocation, transfer, and Performance Lock instructions by electronic notification.Electronic authorizations
          include, but are not limited to, requests received by telephone, fax, email, or on our website. By selecting“yes,” I am authorizing and directing Allianz to act on electronic instructions from me as well as my financial professional and/or anyone
          authorized by him/her to transfer and allocate Contract Value among the variable investment options and any other available allocation options and authorization for Performance Locks. I understand I must approve the transactions recommended by my
          financial professional prior to execution, unless I have given my financial professional discretion over my contract. My financial professional shall maintain all required authorizations pursuant to Form ADV, power of attorney, agreement, or
          otherwise. If the box is not checked, electronic instructions will be accepted only from me, the Owner. Allianz will use reasonable procedures to confirm that these electronic instructions are valid. As long as these procedures are followed, the
          company and its officers, employees, representatives, and/or agents will be held harmless for any claim, liability, loss, or cost arising from unauthorized or fraudulent instructions. We reserve the right to deny any electronic transfer request,
          Performance Lock, or allocation instruction change, and to discontinue or modify our electronic instruction privileges at any time for any reason.]  IXA-APP-02-NF  3  [(4/2019)] 

    

  

   

  
    
      

  

  
    
      

    

    
                                                       Variable OptionsAsset Allocation Cash Equivalent % AZL® MVP
          Balanced Index Strategy Fund % AZL® Government Money Market Fund % AZL® MVP Growth Index Strategy FundIndex Options  Index Performance Strategy  Index Protection Strategy % EURO STOXX 50® % Nasdaq-100® Index % Russell 2000® Index % S&P 500®
          Index % iShares® MSCI Emerging Markets ETF   % EURO STOXX 50®   % Nasdaq-100® Index   % Russell 2000® Index   % S&P 500® Index   % iShares® MSCI Emerging Markets ETF  Index Guard Strategy  Index Precision Strategy % EURO STOXX 50® %
          Nasdaq-100® Index % Russell 2000® Index % S&P 500® Index % iShares® MSCI Emerging Markets ETF   % EURO STOXX 50®   % Nasdaq-100® Index   % Russell 2000® Index   % S&P 500® Index   % iShares® MSCI Emerging Markets ETF  Total of % (must
          equal 100%)              8. Allocation Options (continued)  IXA-APP-02-NF  4  [(4/2019)]  9. Beneficiary Designation (If additional space is needed, attach a complete list signed and dated by Owner(s).)                  Primary
          Contingent  Percentage    Relationship  Social Security Number/TIN        Phone number  Individual first name    MI  Last name    Date of birth (mm/dd/yyyy)      GenderMale Female  Qualified plan Custodian Trust (Include the date of trust in the
          name.) Charitable Trust Non-individual Beneficiary name              Email    Street address        City    State    ZIP code  Primary Contingent  Percentage    Relationship  Social Security Number/TIN        Phone number  Individual first
          name    MI  Last name    Date of birth (mm/dd/yyyy)      GenderMale Female  Qualified plan Custodian Trust (Include the date of trust in the name.) Charitable Trust Non-individual Beneficiary name              Email    Street
          address        City    State    ZIP code  Primary Contingent  Percentage    Relationship  Social Security Number/TIN        Phone number  Individual first name    MI  Last name    Date of birth (mm/dd/yyyy)      GenderMale Female  Qualified plan
          Custodian Trust (Include the date of trust in the name.) Charitable Trust Non-individual Beneficiary name              Email    Street address        City    State    ZIP code 

    

  

   

  
    
      

  

  
    
      

    

    
       10. Financial Professional  Notice to Financial Professional: Applicable product training must be completed
          for the state for which this sale occurred.By signing below, the Financial Professional 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)
          withthe most current prospectus.The Owner statement regarding existing policies or annuity contracts is true and accurate to the best of my knowledge and belief.The Owner statement as to whether or not an existing life insurance policy or annuity
          contract is being replaced is true and accurate to the best of my knowledge and belief.I hereby certify that I only used sales materials that were previously approved by Allianz in my presentation.I further certify that I left a copy of all sales
          material used during my presentation with the applicant.I have provided the Owner with all appropriate disclosure and replacement requirements prior to the completion of this application.If this is a replacement, include a copy of each disclosure
          statement and a list of companies involved.            11. Certification of Taxpayer Identification Number    [If you are applying for this product and/or requesting payments as a U.S. Person, the IRS requires you to agree to the following
          statements. If you are not a U.S. Person, you are not eligible to apply for this product.Under penalties of perjury, I certify that:The Taxpayer Identification Number shown on this form is correct or I am waiting for a number to be issued to me.I
          am not subject to backup withholding because:I am exempt from backup withholding, orI have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of failureto report all interest or dividends,
          orThe IRS has notified me that I am no longer subject to backup withholding.I am a U.S. person, andThe Foreign Account Tax Compliance Act (FATCA) code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is
          correct.Check the box if the IRS has notified you that you are currently subject to backup withholding because you failed to report interest and dividends on your tax return.]    IXA-APP-02-NF  5  [(4/2019)]    Financial Professional’s signature
          (Primary)          First and last name (please print)              Address            Email            Financial Professional’s signature (Secondary)          First and last name (please
          print)              Email                      Broker/dealer name (please print)            Authorized signature broker/dealer (if required)                        Commission options (please check one)A B C                       

    

  

   

  
    
      

  

  
    
      

    

    
       12. Agreements and Signatures        [The following state requires Owners to read and acknowledge the
          statement for your state below.District of Columbia: 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, I, the Owner, acknowledge the applicable statement(s) mentioned above and understand and agree 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 may increase or decrease
          depending on the investment results of the Allocation Options and that there is no guaranteed minimum Variable Account Value.To the best of my knowledge and belief, all statements and answers in this application are complete and true.No
          representative is authorized to modify this agreement or waive any Allianz rights or requirements.If this Contract is being funded by an indirect rollover, I have complied with the requirement that only one rollover is permitted within a one year
          period from all of the IRAs I own.For information on current benefit features, restrictions or charges please review with your Financial Professional.Please send me a statement of additional information. (Also available at
          [www.allianzlife.com])[The IRS does not require your consent to any provision of this document other than the certifications required to avoidbackup withholding.]As the authorized signer, please sign your name and date below in the appropriate
          space or we will not be able to process your request.Signed at (City and State)Owner’s signature: Date: MM/DD/YYYYJoint Owner’s signature: Date: MM/DD/YYYYAlternate signatures, if applicableTrust: as trustee of the: Date: TRUSTEE’S SIGNATURE
          TRUST NAME (PRINTED) MM/DD/YYYYPower of attorney: by: Date: OWNER’S NAME (PRINTED) ATTORNEY IN FACT’S SIGNATURE(S) MM/DD/YYYY    IXA-APP-02-NF  6  [(4/2019)] 

    

  

   

  
    
      

  

  
    
      

    

    
       Please submit your form through one of the options below: Email completed forms
          to:[variableannuity@send.allianzlife.com]ORWeb Upload:You can scan and upload your signed and completed form by logging in to your account at [Allianzlife.com]OR  Mail:[Applications that HAVE a check attached:Regular mailAllianz Life Insurance
          Company of North America NW 5989PO Box 1450Minneapolis, MN 55485-5989]  [Overnight mailAllianz Life Insurance Company of North America NW 59891801 Parkview DriveShoreview, MN 55126]  OR  [Applications that DO NOT HAVE a check attached:Regular
          mailAllianz Life Insurance Company of North America PO Box 561Minneapolis, MN 55440-0561]  [Overnight mailAllianz Life Insurance Company of North America 5701 Golden Hills DriveGolden Valley, MN 55416-1297]  OR[Fax: 763.765.7912][Any questions?
          Call us at 800.624.0197]    IXA-APP-02-NF  7  [(4/2019)] 

    

  

   

  
    
      

  

  
    
      

    

    
       IXA-APP-02-NF  8  [(4/2019)]  [The S&P 500® Index is comprised of 500 stocks representing major U.S.
          industrial sectors.S&P® is a registered trademark of Standard & Poor’s Financial Services LLC (“S&P”). This trademark has been licensed for use by S&P Dow Jones Indices LLC. S&P marks are trademarks of S&P. These
          trademarks have been sublicensed for certain purposes by Allianz Life Insurance Company of North America (“Allianz”). The S&P 500® Index (“the Index”) is a product of S&P Dow Jones Indices LLC and/or its affiliates and have been licensed
          for use by Allianz.Allianz products are not sponsored, endorsed, sold, or promoted by S&P Dow Jones Indices LLC, Dow Jones, S&P, or any of their respective affiliates (collectively, “S&P Dow Jones Indices”). S&P Dow Jones Indices
          make no representation or warranty, express or implied, to the owners of the Allianz products or any member of the public regarding the advisability of investments generally or in Allianz products particularly or the ability of the Index and
          Average to track general market performance. S&P Dow Jones Indices’ only relationship to Allianz with respect to theIndex and Average is the licensing of the Index and Average and certain trademarks, service marks, and/or trade names of
          S&P Dow Jones Indices and/or its third-party licensors. The Index and Average are determined, composed, and calculated by S&P Dow Jones Indices without regard to Allianz or the products. S&P Dow Jones Indices have no obligation to
          take the needs of Allianz or the owners of the products into considerationin determining, composing, or calculating the Index and Average. S&P Dow Jones Indices are not responsible for and have not participated in the design, development,
          pricing, and operation of the products, including the calculation of any interest payments or any other values credited to the products. S&P Dow Jones Indices have no obligation or liability in connection with the administration, marketing,
          or trading of products. There is no assurance that investment products based on the Index and Average will accurately track index performance or provide positive investment returns. S&P Dow Jones Indices LLC and its subsidiaries are not
          investment advisors. Inclusion of a security or futures contract within an index isnot a recommendation by S&P Dow Jones Indices to buy, sell, or hold such security or futures contract, nor is it considered to be investment advice.
          Notwithstanding the foregoing, CME Group Inc. and its affiliates may independently issue and/or sponsor financial products unrelated to products currently being issued by Allianz, but which may be similar to and competitive with Allianz products.
          In addition, CME Group Inc., an indirect minority owner of S&P Dow Jones Indices LLC, and its affiliates may trade financial products which are linked to the performance of the Index and Average. It is possible that this trading activity will
          affect the value of the products.S&P DOW JONES INDICES DO NOT GUARANTEE THE ADEQUACY, ACCURACY, TIMELINESS, AND/OR THE COMPLETENESS OF THE INDEX AND AVERAGE OR ANY DATA RELATED THERETO OR ANY COMMUNICATION, INCLUDING BUT NOT LIMITED TO, ORAL
          OR WRITTEN COMMUNICATION (INCLUDING ELECTRONIC COMMUNICATIONS) WITH RESPECT THERETO. S&P DOW JONES INDICES SHALL NOT BE SUBJECT TO ANY DAMAGES OR LIABILITY FOR ANY ERRORS, OMISSIONS, OR DELAYS THEREIN. S&P DOW JONES INDICES MAKE NO
          EXPRESS OR IMPLIED WARRANTIES, AND EXPRESSLY DISCLAIM ALL WARRANTIES, OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE OR USE OR AS TO RESULTS TO BE OBTAINED BY ALLIANZ, OWNERS OF THE PRODUCTS, OR ANY OTHER PERSON OR ENTITY FROM THE USE OF
          THE INDEX AND AVERAGE OR WITH RESPECT TO ANY DATA RELATED THERETO. WITHOUT LIMITING ANY OF THE FOREGOING, IN NO EVENT WHATSOEVER SHALL S&P DOW JONES INDICES BE LIABLE FOR ANY INDIRECT, SPECIAL, INCIDENTAL, PUNITIVE, OR CONSEQUENTIAL DAMAGES
          INCLUDING BUT NOT LIMITED TO, LOSS OF PROFITS, TRADING LOSSES, LOST TIME, OR GOODWILL, EVEN IF THEY HAVE BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES, WHETHER IN CONTRACT, TORT, STRICT LIABILITY, OR OTHERWISE. THERE ARE NO THIRD-PARTY
          BENEFICIARIES OF ANY AGREEMENTS OR ARRANGEMENTS BETWEEN S&P DOW JONES INDICES AND ALLIANZ OTHER THAN THE LICENSORS OF S&P DOW JONES INDICES.The NASDAQ-100 Index® includes 100 of the largest domestic and international non-financial
          securities listed on The NASDAQ Stock Market® based on market capitalization.The Product(s) is not sponsored, endorsed, sold or promoted by Nasdaq, Inc. or its affiliates (Nasdaq, with its affiliates, are referred to as the “Corporations”). The
          Corporations have not passed on the legality or suitability of, or the accuracy or adequacy of descriptions and disclosures relating to, the Product(s). The Corporations make no representation or warranty, express or implied to the owners of the
          Product(s) or any member of the public regarding the advisability of investing in securities generally or in the Product(s) particularly, or the ability of the Nasdaq-100 Index® to track general stock market performance. The Corporations’ only
          relationship to Allianz Life Insurance Company of North America (“Licensee”) is in the licensing of the NASDAQ®, and Nasdaq-100 Index® registered trademarks, and certain trade names of the Corporationsand the use of the Nasdaq-100 Index® which is
          determined, composed and calculated by NASDAQ without regard to Licensee or the Product(s). Nasdaq has no obligation to take the needs of the Licensee or the owners of the Product(s) into consideration in determining, composing or calculating the
          Nasdaq-100 Index®. The Corporations are not responsible for and have not participated in the determination of the timing of, prices at, or quantities of the Product(s) to be issued or in the determination or calculation of the equation by which
          the Product(s) is to be converted into cash. The Corporations have no liability in connection with the administration, marketing or trading of the Product(s).THE CORPORATIONS DO NOT GUARANTEE THE ACCURACY AND/OR UNINTERRUPTED CALCULATION OF THE
          NASDAQ-100 INDEX® OR ANY DATA INCLUDED THEREIN. THE CORPORATIONS MAKE NO WARRANTY, EXPRESS OR IMPLIED, AS TO RESULTS TO BE OBTAINED BY LICENSEE, OWNERS OF THE PRODUCT(S), OR ANY OTHER PERSON OR ENTITY FROM THE USE OF THE NASDAQ-100 INDEX® OR ANY
          DATA INCLUDED THEREIN. THE CORPORATIONS MAKE NO EXPRESS OR IMPLIED WARRANTIES, AND EXPRESSLY DISCLAIM ALL WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE OR USE WITH RESPECT TO THE NASDAQ-100 INDEX® OR ANY DATA INCLUDED THEREIN.
          WITHOUT LIMITING ANY OF THE FOREGOING, IN NO EVENT SHALL THE CORPORATIONS HAVE ANY LIABILITY FOR ANY LOST PROFITS OR SPECIAL, INCIDENTAL, PUNITIVE, INDIRECT, OR CONSEQUENTIAL DAMAGES, EVEN IF NOTIFIED OF THE POSSIBILITY OF SUCH DAMAGES. 

    

  

   

  
    
      

  

  
    
      

    

    
       IXA-APP-02-NF  9  [(4/2019)]  The Russell 2000® Index is an equity index that measures the performance of
          the 2,000 smallest companies in the Russell 3000® Index, whichis made up of 3,000 of the biggest U.S. stocks. The Russell 2000® Index is constructed to provide a comprehensive and unbiased small-cap barometer and is completely reconstituted
          annually to ensure larger stocks do not affect the performance and characteristics of the true small-cap index.The Russell 2000® Index (the “Index”) is a trademark of Frank Russell Company (“Russell”) and has been licensed for use by Allianz Life
          Insurance Company of North America (“Allianz”). Allianz products are not in any way sponsored, endorsed, sold or promoted by Russell or the London Stock Exchange Group companies (“LSEG”) (together the “Licensor Parties”) and none of the Licensor
          Parties make any claim, prediction, warranty or representation whatsoever, expressly or impliedly, either as to (i) the results to be obtained from the use of the Index (upon which the Allianz product is based), (ii) the figure at which the Index
          is said to stand at any particular time on any particular day or otherwise, or (iii) the suitability of the Index for the purpose to which it is being put in connection with the Allianz product. None of the Licensor Parties have provided or will
          provide any financial or investment advice or recommendation in relation to the Index to Allianz or to its clients. The Index is calculated by Russell or its agent. None of the Licensor Parties shall be (a) liable (whether in negligence or
          otherwise) to any person for any error in the Index or (b) under any obligation to advise any person of any error therein.The EURO STOXX 50®, Europe’s leading Blue-chip index for the Eurozone, provides a blue-chip representation of supersector
          leaders in the Eurozone. The index covers 50 stocks from 11 Eurozone countries: Austria, Belgium, Finland, France, Germany, Ireland, Italy, Luxembourg, the Netherlands, Portugal and Spain.STOXX Limited, Deutsche Börse Group and their licensors,
          research partners or data providers have no relationship to Allianz Life Insurance Company of North America (“Allianz”), other than the licensing of the EURO STOXX 50® and the related trademarks for use in connection with Allianz products.STOXX,
          Deutsche Börse Group and their licensors, research partners or data providers do not:sponsor, endorse, sell or promote Allianz products.recommend that any person invest in Allianz products or any other securities.have any responsibility or
          liability for or make any decisions about the timing, amount or pricing of Allianz products.have any responsibility or liability for the administration, management or marketing of Allianz products.consider the needs of Allianz products or the
          owners of Allianz products in determining, composing or calculating the EURO STOXX 50 or have any obligation to do so.STOXX, Deutsche Börse Group and their licensors, research partners or data providers give no warranty, and exclude any liability
          (whether in negligence or otherwise), in connection with the Allianz products or their performance.STOXX does not assume any contractual relationship with the purchasers of Allianz products or any other third parties.Specifically,STOXX, Deutsche
          Börse Group and their licensors, research partners or data providers do not give any warranty, express or implied, and exclude any liability about:The results to be obtained by Allianz products, the owner of Allianz products or any other person
          in connection with the use of the EURO STOXX50 and the data included in the EURO STOXX 50;The accuracy, timeliness, and completeness of the EURO STOXX 50 and its data;The merchantability and the fitness for a particular purpose or use of the EURO
          STOXX 50 and its data;The performance of Allianz products generally.STOXX, Deutsche Börse Group and their licensors, research partners or data providers give no warranty and exclude any liability, for any errors,omissions or interruptions in the
          EURO STOXX 50 or its data;Under no circumstances will STOXX, Deutsche Börse Group or their licensors, research partners or data providers be liable (whether in negligence or otherwise) for any lost profits or indirect, punitive, special or
          consequential damages or losses, arising as a result of such errors, omissions or interruptions in the EURO STOXX 50 or its data or generally in relation to Allianz products, even in circumstances where STOXX, Deutsche Börse Group or their
          licensors, research partners or data providers are aware that such loss or damage may occur.The licensing Agreement between Allianz and STOXX is solely for their benefit and not for the benefit of the owners of Allianz products or anyother third
          parties.The iShares® MSCI Emerging Markets ETF distributed by BlackRock Investments, LLC. iShares®, BLACKROCK®, and the corresponding logos are registered trademarks of BlackRock, Inc. and its affiliates (“BlackRock”) and are used under license.
          These trademarks have been licensed for certain purposes by Allianz Life Insurance Company of North America (“Allianz”) and its wholly-owned subsidiaries. Products offered by Allianz or its wholly-owned subsidiaries are not sponsored, endorsed,
          sold or promoted by BlackRock, and purchasers of such products do not acquire any interest in the iShares® MSCI Emerging Markets ETF nor enter into any relationship of any kind with BlackRock. BlackRock makes no representations or warranties,
          express or implied, to the owners of any products offered by Allianz or its wholly-owned subsidiaries, or anymember of the public regarding the advisability of purchasing a product from Allianz or its wholly-owned subsidiaries. BlackRock has no
          obligation or liability for any errors, omissions, interruptions or use of the iShares MSCI Emerging Markets ETF or any data related thereto, or with the operation, marketing, trading or sale of any products or services offered by Allianz and its
          wholly-owned subsidiaries.]Exhibit 10.5

 

THIS DEBENTURE, AND ANY SHARES ACQUIRED
UPON CONVERSION HEREOF, HAVE NOT BEEN REGISTERED UNDER THE SECURITIES ACT OF 1933, AS AMENDED, (THE "ACT") OR ANY STATE
SECURITIES LAWS, AND MAY NOT BE SOLD, OFFERED FOR SALE, PLEDGED, HYPOTHECATED, OR OTHERWISE TRANSFERRED IN THE ABSENCE OF (A) AN
EFFECTIVE REGISTRATION STATEMENT UNDER THE ACT AND ANY APPLICABLE STATE SECURITIES LAWS, OR (B) AN OPINION OF COUNSEL ACCEPTABLE
TO COUNSEL FOR THE ISSUER THAT SUCH REGISTRATION IS NOT REQUIRED AND THAT THE PROPOSED TRANSFER MAY BE MADE WITHOUT VIOLATION OF
THE ACT AND ANY APPLICABLE STATE SECURITIES LAW.

 

	$_________________	June __, 2018
	 	Miami, Florida

 

KISSES FROM ITALY, INC.

(a Florida corporation)

 

8% CONVERTIBLE DEBENTURE

Due On or Before June __, 2021

 

KISSES FROM ITALY, INC.,
a Florida corporation (the "Company"), for value received and intending to be legally bound, hereby promises to pay to
the order of ___________________________________________, ("Holder"), the principal amount of ________________________________Dollars
($___________) on or before June __, 2021, together with interest thereon as set forth herein.

 

1.       Convertible
Debenture. By accepting this Debenture, the Holder hereby acknowledges that this Debenture has not been registered under the
Securities Act of 1933, as amended, or any state securities laws and Holder represents for himself and his legal representative
that he is acquiring this Debenture and will acquire any shares issued upon conversion hereof, for his own account, for investment
purposes only and not with a view to, or for sale in connection with, any distribution of such securities and Holder agrees to
reaffirm, in writing, this investment representation at the time of exercise of the conversion right set forth herein.

 

2.       Principal
and Interest Payment.  Interest on the principal balance due hereunder shall be calculated at the rate of eight percent (8%)
per annum and shall be paid annually, on or before February 15 of each year that this Debenture remains unpaid. Payment of principal
and all remaining accrued interest on this Debenture shall be made on or before June __, 2021 in lawful money of the United States
of America, by delivery of a check payable in immediately available funds to the Holder at Holder's address, or such other manner
acceptable to Holder.

 

3.       Conversion
of Debenture. This Debenture may be converted into shares of Common Stock of the Company at any time prior to the Company’s
Common Stock being approved for trading in the United States. If Holder timely elects to convert this Debenture, Holder shall do
so pursuant to the following terms and conditions:

 

(a)       Conversion.
Prior to the Company’s Common Stock being approved for trading (of which there is no assurance), the Holder may elect to
convert all or a portion of this Convertible Debenture into shares of the Company’s Common Stock at a conversion price of
$0.0667 per share. Any election to convert the Convertible Debenture pursuant to this paragraph shall be effectuated by the Holder
timely submitting to the Company a notice of conversion attached hereto as Exhibit "1" (the "Conversion Notice").
The Conversion Notice shall state the dollar amount thereof to be so converted and shall include or be accompanied by representations
as to the Holder's investment intent substantially similar to those contained in this Debenture. Shares issuable upon conversion
of the Debenture shall be issued in the name of the Holder and shall be transferable only in accordance with all of the terms and
restrictions contained herein. No fractional Shares shall be issued or delivered upon conversion of the Debenture. Upon conversion
of the entire balance of this Debenture, the principal represented thereby shall be canceled upon delivery of the Debenture to
the offices of the Company.

 

(b) Subdivision
or Combination. Whenever the Company shall subdivide or combine the outstanding shares of Common Stock issuable upon conversion
of this Debenture, the Conversion Price in effect immediately prior to such subdivision or combination shall be proportionately
decreased in the case of subdivision or increased in the case of combination effective at the time of such subdivision or combination.

 

 

 

    	 	1	 

     

    

 

(c) Reclassification
or Change. Whenever any reclassification or change of the outstanding shares of Common Stock shall occur (other than a
change in par value, or from par value to no par, or from no par to par value, or as a result of a subdivision or combination),
effective provision shall be made whereby the Holder shall have the right, at any time thereafter, to receive upon conversion of
this Debenture the kind of stock, other securities or property receivable upon such reclassification by a holder of the number
of shares of Common Stock issuable upon conversion of this Debenture immediately prior to such reclassification. Thereafter, the
rights of the parties hereto with respect to the adjustment of the amount of securities or other property obtainable upon conversion
of this Debenture shall be appropriately continued and preserved, so as to afford as nearly as may be possible protection of the
nature afforded by this subparagraph (c).

 

(d)       Merger.
If, prior to repayment of the obligations relevant hereto, or prior to conversion of this Debenture into equity in the Company,
the Company shall be consolidated or merged with another company, or substantially all of its assets shall be sold to another company
in exchange for stock with the view to distributing such stock to its shareholders, each share of stock into which this Debenture
is convertible shall be replaced for the purposes hereof by a pro rata amount of the securities or property issuable or distributable,
based upon the percentage of the Company's common stock which a Holder would have owned had a there been a conversion herein after
consummation of such merger, consolidation or sale and adequate provision to that effect shall be made at the time thereof. The
Company will provide the Holder at least thirty (30) days prior written notice of any event described in this subsection (d).

 

(e)       Reservation
of Common Shares. The Company shall take or has taken all steps necessary to reserve a number of its authorized
but unissued Common Shares sufficient for issuance upon conversion of this Convertible Subordinated Debenture pursuant to the provisions
included hereinabove.

 

(f)       Securities
Laws Restrictions. This Debenture and the Common Shares issuable upon conversion have not been registered for sale
under the Securities Act of 1933, as amended and neither this Debenture nor those shares nor any interest in this Debenture nor
those shares may be sold, offered for sale, pledged or otherwise disposed of without compliance with applicable securities laws,
including, without limitation, an effective registration statement relating thereto or delivery of an opinion of counsel acceptable
to the Company that such registration is not required under the Securities Act of 1933.

 

(g)       Status
of Registered Holder. The Company may treat the registered holder of this Debenture as the absolute owner of this Debenture
for the purposes of making payments of principal or interest and for all other purposes and shall not be affected by any notice
to the contrary.

 

(h)       Redemption/Prepayment
of Debenture. This Debenture is subject to redemption at the option of the Company upon 30 days prior written notice (subject
to the Holder's prior exercise of its right of conversion as set forth above), as a whole at any time, or in part from time to
time, upon payment by the Company of 100% of the unpaid principal amount or such portion thereof so redeemed, plus accrued interest
thereon through the date of redemption.

 

4. Events of Default. 
If any of the following conditions or events ("Events of Default") shall occur and be continuing:

 

(a) if the
Company shall default in the payment of principal and/or interest accruing herein when the same becomes due and payable, whether
at maturity or by declaration of acceleration or otherwise, and shall fail to cure such default within seven days after written
notice thereof from the Holder to the Company, if the Company fails to tender any payment due hereunder when the same becomes due;
and shall fail to cure such default within seven days after written notice thereof from the Holder to the Company, or

 

(b) if the
Company shall materially default in the performance of or compliance with any term contained herein and such default shall not
have been remedied within fifteen days after written notice thereof from the Holder to the Company; or

 

(c) if the
Company shall make an assignment for the benefit of creditors, or shall admit in writing its inability to pay its debts as they
become due, or a voluntary petition for reorganization under Title 11 of the United States Code ("Title 11") shall be
filed by the Company or an order shall be entered granting relief to the Company under Title 11 or a petition shall be filed by
the Company in bankruptcy, or the Company shall be adjudicated a bankrupt or insolvent, or shall file any petition or answer seeking
for itself any reorganization, arrangement, composition, readjustment, liquidation, dissolution or similar relief under any present
or future statute, law or regulation, or shall file any answer admitting or not contesting the material allegations of a petition
filed against the Company in any such proceeding, or shall seek or consent to or acquiesce in the appointment of any trustee, receiver
or liquidator of the Company or of all or any substantial part of the properties of the Company or if the Company or its directors
or majority shareholders shall take any action looking to the dissolution or liquidation of the Company; or

 

 

 

    	 	2	 

     

    

 

(d) if within
120 days after the commencement of an action against the Company seeking a reorganization, arrangement, composition, readjustment,
liquidation, dissolution or similar relief under any present or future statute, law or regulation, such action shall not have been
dismissed or nullified or all orders or proceedings thereunder affecting the operations or the business of the Company stayed,
or if the stay of any such order or proceeding shall thereafter be set aside, or if, within 120 days after the appointment without
the consent or acquiescence of the Company of any trustee, receiver or liquidator of the Company or of all or any substantial part
of the properties of the Company such appointment shall not have been vacated;

 

then, and in any such event,
the Holder may at any time (unless such Event of Default shall theretofore have been remedied) at its option, by written notice
to the Company, declare the Debenture to be due and payable, whereupon the Debenture shall forthwith mature and become due and
payable, together with interest accrued thereon, and thereafter interest shall be due, at the rate per annum hereinabove provided,
on the entire principal balance until the same is fully paid, and on any overdue interest (but only to the extent permitted by
law), without presentment, demand, protest or notice, all of which are hereby waived, subject however, to the other terms, including
those relating to subordination, of this Debenture.

 

In the case of a default in the
payment of any principal of or interest on the Debenture, the Company will pay to the Holder such further amount as shall be sufficient
to cover the cost and expenses of collection, including, without limitation, reasonable attorneys' fees, expenses and disbursements.
No course of dealing and no delay on the part of Holder in exercising any right shall operate as a waiver thereof or otherwise
prejudice such Holder's rights, powers or remedies. No right, power or remedy conferred by this Debenture upon Holder shall be
exclusive of any other right, power or remedy referred to herein or now or hereafter available at law, in equity, by statute or
otherwise.

 

5. Usury Laws. Notwithstanding
any provision contained in this Debenture to the contrary, the Company's liability for payment of interest shall not exceed the
limits imposed by applicable usury law. If any provision hereof requires interest payments in excess of the then legally permitted
maximum rate, such provision shall automatically be deemed to require such payment at the then legally-permitted maximum rate.

 

6. Notices. All notices
required or permitted to be given under this Debenture shall be in writing (delivered by hand or sent certified or registered mail,
return receipt requested, or by nationally recognized overnight courier service) addressed to the following addresses:

 

	If to Holder:	 _____________________________
	 	______________________________
	 	______________________________
	 	 
	If to Company:	KISSES FROM ITALY, INC.
	 	______________________________
	 	______________________________
	 	Attn: President

 

All notices shall be deemed given
upon receipt by the recipient.

 

6. Governing Law. This Debenture
shall be governed by the laws of the State of Florida.

 

7. Severability. If any provision,
paragraph or subparagraph of this Agreement is adjudged by any court to be void or unenforceable in whole or in part, this adjudication
shall not affect the validity of the remainder of the Agreement, including any other provision, paragraph or subparagraph. Each
provision, paragraph or subparagraph of this Agreement is separable from every other provision, paragraph and subparagraph and
constitutes a separate and distinct covenant.

 

 

 

    	 	3	 

     

    

 

8. Amendment. This Agreement may
only be amended in writing, duly endorsed by the parties hereto.

 

9. Headings. The headings in this
Debenture are solely for convenience of reference and shall not affect its interpretation.

 

 

	Attest:	 
	 	KISSES FROM ITALY, INC.
	 	 
	 	 
	_______	By: ______________________
	Secretary	President

 

 

 

 

 

 

 

 

 

 

    	 	4	 

     

    

 

EXHIBIT "1"

 

CONVERSION NOTICE

 

TO:KISSES FROM ITALY, INC.

 

The Holder listed below
hereby irrevocably exercises his/her/its right to convert ____% ($______) of this Debenture into shares of Common Stock of KISSES
FROM ITALY, INC. at the Conversion Price of $______ per share in accordance with the terms of this Debenture, and directs that
the Common Shares issuable and deliverable upon such conversion, be registered in the name of the Holder on the books and records
of KISSES FROM ITALY, INC. and delivered to the Holder.

 

The Holder hereby acknowledges
that the Common Shares (i) have not been and will not be at the time of acquisition by the undersigned registered under the Securities
Act of 1933, as amended, or under any state securities laws, and hereby represents and warrants to the Company that he is acquiring
the Common Shares for his own account, for investment, and not with a view to, or for sale in connection with, any distribution
of such Common Shares; and (ii) are transferable only in accordance with all the terms and restrictions contained in the Debenture.

 

 

Dated:_______________ , 20___

 

 

	                                                          	________________________________
	Witness	Signature of Holder
	 	 
	 	________________________________
	 	(Print Name of Holder)
	 	 
	 	________________________________
	 	Social Security Number or EIN                     
	 	 
	 	________________________________
	 	Address
	 	 
	 	________________________________

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