AXA EQUITABLE LIFE INSURANCE COMPANY APPLICATION FOR EQUI-VEST STRATEGIES TSA (SERIES 901) GROUP FLEXIBLE PREMIUM COMBINATION FIXED AND VARIABLE DEFERRED ANNUITY CONTRACT (Consisting of Parts A and B)

Exhibit 4(p)

AXA EQUITABLE LIFE INSURANCE COMPANY

APPLICATION FOR EQUI-VEST STRATEGIES TSA (SERIES 901) GROUP FLEXIBLE PREMIUM

COMBINATION FIXED AND VARIABLE DEFERRED ANNUITY CONTRACT

(Consisting of Parts A and B)

Part A

Section I - Application and Agreement for Participation in EQUI-VEST^® Strategies Contract

1. Distributor (Please check one)		¨       AXA Advisors ¨       AXA Distributors
	2. Type of EQUI-VEST Strategies Contract (Please check one)			¨       403(b) Public, Charter or Private Schools (K-12) ¨       501(c)(3) ¨       Higher Education (Colleges and Universities) Is the Plan subject to ERISA?    ¨  Yes    ¨  No (Note: A governmental entity including a Public School is not subject to ERISA)
3. Employer and Plan Information		Employer’s Name:__________________________________________________________________
			Employer’s Address:________________________________________________________________
		Number and Street (If non-U.S., Registered Representative must contact Branch.)
		______________________________________________________________
		Attention
		______________________________________________________________
		City                                          State                                          Zip Code
		Employer’s Federal Taxpayer’s Identification Number: ____________________________________
		Plan Name: _____________________________________________________________________
		Plan’s Contact Person Name: ________________________________________________________
		Contact’s Telephone Number: ___________________________ extension______________________
		Contact’s Email Address:___________________________________________________________
	4. Key Registered Representative or Broker of Record’s Name and Code Number		Name: __________________________________________________________________________ Code Number: ____________________________________________________________________ Firm Name (Broker): _______________________________________________________________ CV #: ____________ (For Internal Use Only)

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5. Plan Effective Date		Indicate the date the Plan went into effect. Year __________ Month__________ Day________
6. Administrative Charge Payment		Annual Administrative Charge for each Certificate on the last day of each Participation Year is to be:
		¨       Deducted from each Participant’s Account Value ¨       Paid by the Employer
		Note: Employers that elect to pay the Annual Administrative Charge must have a minimum of 5 Participants at the time the Unit is established.
7. Loan Information		Does the Plan permit Participants to take loans?    ¨  Yes    ¨  No
		Unless you or your designee provides us with the loan interest rate on Participant loan requests, AXA Equitable will set the loan interest rate. We will use the rate as published in the Wall Street Journal for the Prime Interest Rate +1.00% on a calendar monthly basis.
		Does the plan have a limit on the number of loans that a Participant can have under this Contract (limit may not exceed nine)?
		¨  Yes     ¨   No
		If Yes, please provide the maximum number of loans permitted under the Plan:_____________
8. Hardship Withdrawal Information		Does the Plan permit Participants to take Hardship Withdrawals?    ¨  Yes    ¨  No
9. Catch-Up Contributions		Does the Plan permit Catch-Up Contributions? (select one box only)
		¨       Age 50
		¨       15 Years of Service
		¨       Both Age 50 and 15 Years of Service
		¨       None
10. Direct Rollover, Transfer and Exchange Contributions and In-Plan Xxxx Conversions		Does the Plan permit:
		Direct Rollover Contributions?    ¨  Yes    ¨  No
		Plan-to-Plan Direct Transfer Contributions?    ¨  Yes    ¨  No
		Direct Transfer Contributions that are Contract Exchanges under the same Plan?    ¨  Yes    ¨  No
		In-Plan Xxxx Conversions?    ¨  Yes    ¨  No
		If Contract Exchanges are permitted, indicate the vendors with whom they can be made:
		¨       All vendors named in the Plan for Contributions, Transfers and Exchanges
		¨       Only those vendors named in the Plan for Transfers and Exchanges
		¨       Other (specify): _______________________________________________
		Indicate on the 403(b) Plan Approved Provider List on page 11, all vendors that are approved 403(b) Contract providers under the Plan for accepting Transfers and Exchanges.

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11. Payouts Permitted Under the Plan		Indicate all methods of payout that are permitted under the Plan (Not to exceed single or joint life expectancy):
		¨       All payout methods available under the Plan’s funding vehicles
		¨       Single Sum
		¨       Periodic Payment
		¨       Annuity Payments
		¨       Other (specify): ____________________________________
12. Existing Plan Assets		Upon takeover, are existing Plan assets being transferred to an Unallocated Account maintained by the Contract until such Plan assets can be allocated to the Participants’ Accounts?    ¨  Yes    ¨  No
13. Sources of Contribution		Indicate which sources (Contribution types) can be made under this Plan. A maximum of 8 sources will be available for each Plan.
		For Internal Use Only
		i. Employee Salary Reduction Contributions (Elective Deferral Contributions):
		Contributions under a salary reduction agreement that an employee enters into with the Employer under the Plan. (For periodic Contributions and/or transfers of the same type from other funding vehicles maintained by the Plan.)
		a.		¨ Pre-Tax Contributions		O
		b.		¨ Designated Xxxx Contributions		H
		ii. ¨ Employer Qualified Non-Elective and Qualified Matching Contributions: Contributions made by the Employer to meet the requirements of the nondiscrimination tests set forth in the Code. (Only applicable for ERISA Plans)				V
		iii. ¨ Employee Non-Xxxx After Tax Contributions:				I
		Amounts reported by the Employer as having Non-Xxxx post-tax consequences under section 415 of the Code. (Includes loan repayment post-default – see Loan Information)
		iv. ¨ Employer Matching Contributions:				J
		Employer Contributions matching Employee Contributions under the terms of the Plan. (For periodic contributions and/or transfers from other funding vehicles maintained by the Plan.)
		v. ¨ Employer Non-Matching Discretionary Contributions:				L
		vi. ¨ Rollover Contributions:				8
		Contributions of eligible rollover distributions directly or indirectly from eligible retirement Plans under the Code.
		vii. ¨ Designated Xxxx Rollover Contributions:				Z
		Contributions of eligible Xxxx rollover distributions directly or indirectly from eligible retirement Plans under the Code.
		viii. ¨ 403(b)(7) Employee Salary Deferrals – Pre Tax:				G
		(Direct Transfer of amounts that were custodial accounts maintained for the Participants by the Plan).
		ix. ¨ 403(b)(7) Employer Contributions:				4
		(Direct Transfer of amounts that were custodial accounts maintained for the Participants by the Plan).

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14.

Vesting

Schedule

Does your Plan document specify a vesting schedule for Employer Contributions?    ¨  Yes    ¨  No

If yes, please indicate the vesting schedule for your Plan:

				¨				¨				¨				¨				¨				¨				¨
		Period of Vesting Service		Schedule A				Schedule B				Schedule C				Schedule D				Schedule E				Schedule F				Schedule G TBD by Client
		< 1 Year			0	%			0	%			0	%			0	%			0	%			0	%
		1 - 2 Years			100	%			0	%			0	%			0	%			0	%			0	%
		2 - 3 Years			100	%			100	%			0	%			0	%			0	%			20	%
		3 - 4 Years			100	%			100	%			100	%			0	%			0	%			40	%
		4 - 5 Years			100	%			100	%			100	%			100	%			0	%			60	%
		5 - 6 Years			100	%			100	%			100	%			100	%			100	%			80	%
		6 Years or >			100	%			100	%			100	%			100	%			100	%			100	%

15. Frequency of Plan Contributions		¨ Monthly                 ¨ Semi-Monthly                 ¨ Bi-Weekly
16. Designated Plan		______________________________________________________________________________________
Administrator		Name of Plan Administrator                                                                                           Telephone Number
(If other than the Employer)		______________________________________________________________________________________
		Address                                         City                                         State                                     Zip Code
		______________________________________________________________________________________
		Contact Person Name, Title                        Email Address                                                 Fax Number
17. Designated Plan Administrator Fee
		If a Designated Plan Administrator is indicated, the Plan Administrator’s fee is to be deducted from each Participant’s Account Value:    ¨  Yes    ¨  No
			If yes, indicate amount for each Participant: $__________
			Frequency:    ¨ Annually                    ¨ Quarterly                    ¨ Monthly
18. Transaction Authorization
		Please indicate whether or not Participants are authorized to execute the following transactions without the Employer’s approval:
		Investment Option Transfers                                                 ¨  Yes    ¨   No
		Allocation Changes                                                               ¨  Yes    ¨   No

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19. Authorization Information Please provide us with the individual(s) authorized to approve transaction(s) (i.e. loans, withdrawals etc.):

		Name:				Signature:
		Telephone Number:				Effective Date:
		Name:				Signature:
		Telephone Number:				Effective Date:

20. Investment Option Methods		Please select the investment option method that will be available to Plan Participants (select only one):
		(a)    ¨ Make their own investment choices (Either Maximum Transfer Flexibility, or Maximum Investment Option Choice)
		(b)    ¨ Have Maximum Transfer Flexibility
		(c)    ¨ Have Maximum Investment Option Choice

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Section II – Plan Location and Contribution Reminder Statement Information

Note: This Section must be completed if the Plan wants to receive Contribution Reminder Statements. If the Plan has more than one location that wants to receive a Contribution Reminder Statement, a fully completed Section II is required for each location designated. A copy of Section II may be reproduced locally.

21. Plan Location Information		Does the location request Contribution Statements?		¨ Yes		¨ No
		Is the Location Name the same as the Employer Name?		¨ Yes		¨ No
		Is the Location Address the same as the Employer Address?		¨ Yes		¨ No
		If either the Location Name or Address is different from the Employer Name or Address please complete the following:

   Location Name:

   Attention of:

   Location Address:

Number and Street

                                     ________________________________________________________________________

City State Zip Code

22. Contribution Statements		Information for the Contribution Statements:
		a.      Contribution Due Date (choose the 1st through 28th of the month)
		Month                                              Day
		b.      Please indicate the frequency in which Contribution Statements are to be forwarded to you.
		¨ Monthly         ¨ Semi-Monthly         ¨ Bi-Weekly
		Please note: The contribution frequency does not have to be the same for all locations.
		c.      Indicate how you wish to have the Contribution Statement produced:
		¨ Alphabetical order
		¨ Certificate Number order
		¨ Social Security Number order
		d.      Do you want the contribution amount(s) to be printed on the Contribution Statements?
		¨  Yes        ¨   No

23. Location Contact Information		Location Contact Person: ___________________________________________________________________
		Location Contact Person’s Telephone Number ______________________ extension _____________________
		Location Contact Person’s Email Address _______________________________________________________

24. Mailing Information Confirmation Notices and Statements of Account will be mailed to the Participants.

FOR PROCESSING USE ONLY:

PLAN ID:                             LOCATION                                 

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Section III – Trust Participation and Contract Holder Information

25.

Trust

Participation

and

Contract

Holder

Information

The Employer and Plan Trustee hereby adopt and agree to participate in the Group Variable Deferred Flexible Premium Annuity Trust of AXA Equitable Life Insurance Company (“Trust”) its successors and assignees.

¨  Yes     ¨  No     (Note: If yes, the “Trust” will be the Contract Holder.)

If the response above is no, specify the name of Contract Holder to be designated under the Contract: (check the appropriate box)

(Generally

for ERISA

Plans)

(i)     ¨   The Employer identified on page 1

(ii)    ¨  Other (Please Specify) _______________________________________________________________

Name of the Trust: ________________________________________________________________________

Address of the Trust: ______________________________________________________________________

                                   Street and Number

                                       ______________________________________________________________________

City State Zip

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Section IV – Basic Installation Information

26. Administration Information		Type of Employer Organization:
		¨ Church Group		¨ Hospital		¨ Healthcare Organization
		¨ City College / University		¨ Public School		¨ State College/ University
		¨ Post-Secondary School		¨ IRC 501(c )(3) Organization		¨ Vocational School
		¨ Governmental Entity
		¨ Other: __________________________________________________________________________
				Please Specify

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Part B

Certain
Contract Provisions		I.      Investment Options - (Contract Section 2.01)
		The Investment Options currently available under the Contract are listed in Attachment A.
		One of the following two methods for selecting Investment Options is available under the Contract:
		1)      Maximum Investment Options: Participants may allocate Contributions or transfer funds to both Type A and Type B Investment Options. The Options currently available are listed in Attachment A (the Investment Options Chart). However, there will be restrictions on the amounts that can be transferred out of the Guaranteed Interest Option.
		2)      Maximum transfer flexibility: Participants may allocate Contributions to any available Investment Options under Type A. No restrictions will apply to amounts that can be transferred out of the Guaranteed Interest Option.
		II.     Guaranteed Interest Option – (Contract Section 2.02)
		Minimum Guaranteed Interest Rate: Not less than 1% and not more than 3%.
		III.   Minimum Aggregate Contributions (on an annual basis) – (Contract Section 3.01)
		$0 - $5 Million
		IV.   Allocations – (Contract Section 3.02)
		Restrictions on Allocations into the Guaranteed Interest Option: No more than 25% of any Contribution may be allocated to the Guaranteed Interest Option. We may suspend these allocation restrictions upon notice to Participants. We will advise Participants of any such liberalization. We will also advise Participants at least 45 days in advance of the day we intend to reimpose any such restrictions, unless we have previously specified that date when we notified Participants of the liberalization.
		V.     Transfer Rules – (Contract Section 4.02)
		The provisions of Section 4.02 of the Contract shall govern except that the maximum percentage of the amount in the Guaranteed Interest Option, which may be transferred, as described in Section 4.02 of the Contract, is the greater of 25% or the total amount transferred during the previous twelve months.
		Restrictions on Transfers into the Guaranteed Interest Option: Transfers into the Guaranteed Interest Option will not be permitted if it would result in more than 25% of the Annuity Account Value to be in the Guaranteed Interest Option. We may suspend these transfer restrictions upon notice to Participants. We will advise Participants of any such liberalization. We will also advise Participants at least 45 days in advance of the day we intend to reimpose any such restrictions, unless we have previously specified that date when we notified Participants of the liberalization.
		VI.   Withdrawal Charges – (Contract Section 9.01)
		For Plans subject to a Withdrawal Charge, each Participation Year, the Participant is permitted to withdraw up to 10% of the Annuity Account Value (less any prior withdrawals and associated withdrawal charges in the current Participation Year) without incurring a Withdrawal Charge.
		The Withdrawal Charge will be assessed as a percentage of the amount withdrawn starting from the Participation Date of each Participant’s Certificate as follows:
		•    10 Years: 6%, 6%, 6%, 6%, 6%, 5%, 4%, 3%, 2%, 1%, or
		•    7 Years: 6%, 6%, 5%, 4%, 3%, 2%, 1%, or
		•    5 Years: 5%, 5%, 5%, 5%, 5%, or
		•    None, or

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The Withdrawal Charge will be assessed as a percentage of each Contribution withdrawn attributable to Contributions made during the current and five prior Participation Years based on the following percentages:

•    5%, 5%, 5%, 5%, 5%, 5%, or

•    5%, 5%, 5%, 5%, 5%, 5% until the beginning of the 13^th Participation Year when the charge becomes zero, or

The Withdrawal Charge will be assessed as a percentage of the amount withdrawn from each Participant’s Certificate starting from the Contract Date of the Group Contract as follows:

•    5 Years: 5%, 5%, 5%, 5%, 5%

•    3 Years: 6%, 6%, 6%

No Withdrawal Charge will apply when:

(Standard Waivers)

1)      after 5 Participation Years, the Participant reaches age 55 and xxxxxx from employment; or

2)      the later of the completion of at least five Participation Years and the Participant’s attainment of 59 ¹/2; or

3)      a request is made for a refund of a Contribution in excess of the amount that may be contributed under Section 403(b) of the Code within one month of the date on which the Contribution is made; or

4)      the Participant’s attainment of age 55, the completion of at least five Participation Years and the receipt by AXA Equitable of a properly completed settlement election form providing for the application of the Annuity Account Value to purchase an eligible Annuity Certain; or

5)      the Participant’s completion of at least three Participation Years and the receipt by AXA Equitable of a properly completed settlement election form providing for the application of the Annuity Account Value to purchase a Period Certain Annuity, where the certain period of such annuity is least ten years; or

6)      the receipt by AXA Equitable of a properly completed settlement election form providing for the application of the Annuity Account Value to purchase a life annuity distribution, pursuant to the terms of this Contract; or

7)      the Participant dies and a death benefit is payable to the Beneficiary; or

8)      the withdrawal is made to satisfy minimum distribution requirements under Code Section 401(a)(9); or

9)      the Participant elects a withdrawal that qualifies as a hardship withdrawal under the Code; or

10)   the Participant has qualified to receive Social Security disability benefits as certified by the Social Security Administration; or

11)   AXA Equitable receives proof satisfactory to us that the Participant’s life expectancy is six months or less, and such proof must include, but is not limited to, certification by a licensed physician; or

12)   the Participant has been confined to a nursing home for more than 90 days (or such other period, as required in your state) as verified by a licensed physician. A nursing home for this purpose means one that is (a) approved by Medicare as a provider of skilled nursing care service, or (b) licensed as a skilled nursing home by the state or territory in which it is located (it must be within the United States, Puerto Rico, U.S. Virgin Islands, or Guam) and meets all of the following:

•    its main function is to provide skilled, intermediate, or custodial nursing care;

•    it provides continuous room and board to three or more persons;

•    it is supervised by a registered nurse or licensed practical nurse;

•    it keeps daily medical records of each patient;

•    it controls and records all medications dispensed; and

•    its primary service is other than to provide housing for residents.

         The withdrawal charge will apply if the condition as described in items 10 through 12 existed at the time the [Participant’s Certificate is issued][Contract is issued] or if the condition began within the 12 month period following the issuance of the [Participant’s Certificate][Contract].

(Benefit Sensitive Waiver)

13)   the Participant xxxxxx from employment.

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VII. Third Party Transfer (Contract Section 9.02)

Currently $25. AXA Equitable reserves the right to charge a maximum of $65 for each occurrence of a withdrawal for any reason, to cover administrative processing costs.

VIII. Annual Administrative Charge - (Contract Section 9.04)

If applicable, the Annual Administrative Charge will be deducted from each certificate on the last day of each Participation Year as follows:

•      The lesser of 2% of the Annuity Account Value plus any prior withdrawals made during the Participation Year or $30; waived at an Annuity Account Value of $15,000 or more, or

•      The lesser of 2% of the Annuity Account Value plus any prior withdrawals made during the Participation Year or $30; waived at an Annuity Account Value of $25,000 or more, or

•      The lesser of 2% of the Annuity Account Value any prior withdrawals made during the Participation Year or $15; waived at an Annuity Account Value of $15,000, or more, or

•      The lesser of 2% of the Annuity Account Value plus any prior withdrawals made during the Participation Year or $15; waived at an Annuity Account Value of $25,000, or more, or

•      None

IX.   Variable Separate Account Charge – (Contract Section 9.06)

0.00% - 2.00%

X.     Participant Accounts (Contract Section 8.01) and Termination of the Contract – (Contract Section 11.08)

Participant consent is required for the Employer to make withdrawals from or terminate a Participant’s account under the Contract. It is the Employer’s responsibility to obtain Participant consent.

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403(b) Plan Approved Provider List		The Vendor(s) named below is/are the approved 403(b) Contract Provider(s) under the Employer’s Plan for ongoing Contributions and/or the acceptance of Transfers & Exchanges until notified otherwise.
		Important Note: The Provider contact information entered below must be for the vendor’s service/processing office, not that of the Registered Representatives who are representing the vendor.

Contact Information

Provider Name/Address		Name / Email (required) / Phone / Fax		Payroll Deduction Contributions		Transfers		Exchanges
AXA Equitable EQUI-VEST Processing Office 000 Xxxxxxx Xxxxxx, Xxxxx 0000 Xxxxxxxx, XX 00000		AXA Equitable 403(b) Desk Ph. (000) 000-0000 or (000) 000-0000 Fax (000) 000-0000 Email: 000xxxxx@xxx-xxxxxxxxx.xxx		¨		¨		¨
				¨		¨		¨
				¨		¨		¨
				¨		¨		¨
				¨		¨		¨
				¨		¨		¨
				¨		¨		¨
				¨		¨		¨
				¨		¨		¨
				¨		¨		¨
				¨		¨		¨
				¨		¨		¨
				¨		¨		¨
				¨		¨		¨

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Acknowledgements and Agreement		When you sign this Application, you are agreeing to the elections that you have made in this Application and acknowledge that you understand the terms and conditions set forth in this Application.
		By signature(s) on the next page of duly authorized person(s), the Employer and or the Trustee(s) if applicable, hereby:
		1.      acknowledge having received and read the most current EQUI-VEST Strategies Prospectus and any Prospectus Supplement(s) for participation under the Contract.
		2.      acknowledge, understand and agree to: the elections made in this Application, the various levels of fees, charges, and funding arrangements under the Contract.
		3.      acknowledge and represent that the Plan meets the requirements of Section 403(b) of the Internal Revenue Code and is sponsored by an eligible Employer, and further acknowledge if the answer to the question (page 1) in Part A, states so, that the Plan is subject to the Employee Retirement Income Security Act of 1974, as amended (ERISA);
		4.      apply for participation in the Contract as funding vehicle for the Plan;
		5.      agree to be bound by the terms and conditions of the Contract;
		6.      acknowledge and understand that no Registered Representative of AXA Advisors or of a Broker Dealer with which AXA Advisors or AXA Distributors has entered into a selling agreement has authority to make or modify any contract or agreement on AXA Equitable’s behalf, or to waive or alter any of AXA Equitable’s rights or requirements; and
		7.      acknowledge and agree that the provisions contained in this Application and the Contract issued upon acceptance of this Application by AXA Equitable supersede all prior agreements that may have previously been entered into between the Employer and AXA Equitable.
		8.      acknowledge, understand and agree that all forfeiture funds, if any, will be re-allocated among remaining Participants to offset future Employer Contributions.
		9.      acknowledge, understand and agree that assets transferred from a prior funding vehicle are received by AXA Equitable, such assets will be deposited as one lump sum to an Unallocated Account in the Guaranteed Interest Option. Assets shall remain in this account until all forms are completed and until all information needed to complete the transfer is received by AXA Equitable. With respect to each Participant, AXA Equitable will allocate amounts to each Participant’s Certificate only after you provide instructions that are acceptable and necessary in order to complete the allocation process. Once all the necessary information is received and has been determined to be acceptable by AXA Equitable, AXA Equitable will allocate such amounts to each Participant’s Certificate. You are solely responsible for effectuating the asset transfer in accordance with all applicable laws and regulations.
		10.    understand that by identifying the Designated Plan Administrator (page 4) and signing on the next page, the Employer and or the Trustee(s) are authorizing AXA Equitable to provide information regarding the Plan and Plan Participants to them.
		11.    understand that the Annuity Account Value attributable to allocations to the Variable Investment Options may increase or decrease and are not guaranteed as to dollar amount.
		12.    understand that the Employer’s legal counsel and/or advisor should determine that there are no local or state laws, rules and/or regulations which prohibit the investment of Plan assets in the Contract and in the Investment Options indicated on Attachment A of this Application.

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Fraud Warning:

In Arkansas, Massachusetts, New Mexico, 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.

In D.C. WARNING: it is a crime to provide false or misleading information to an insurer for the purpose of
defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an
insurer may deny insurance benefits if false information materially related to a claim was provided by the
applicant.

In Kentucky: It is a crime 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.

In Louisiana: 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/enrollment form for insurance is guilty of a crime
and may be subject to fines and confinement in prison.

In Maine: It is a crime to knowingly provide false, incomplete or misleading information to an insurance
company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial
of insurance benefits.

In Minnesota: Any person who knowingly and with intent to defraud any insurance company files an
enrollment form/application or statement of claim containing any materially false, misleading or incomplete
information may be guilty of a crime which may be punishable under state or Federal law.

In Ohio: Any person, who with intent to defraud or knowing that he is facilitating a fraud against an insurer,
submits an enrollment form/application or files a claim containing a false or deceptive statement is guilty of
insurance fraud.

In Oklahoma: 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.

In Washington: It is a crime to knowingly provide false, incomplete or misleading information to an
insurance company for the purposes of defrauding the company. Penalties include imprisonment, fines and
denial of insurance benefits.

FOR CONTRACT HOLDER(S):(If the Contract Holder is the Employer or the Trust as defined in Section III,
complete (a) below; If the Contract Holder is other than the Employer or the Trust, complete (a) and (b) below.)

(a) __________________________________________________________________________________

    Print Name of Authorized Individual/Employer                         City                         State

By __________________________________________________________________________________

    Signature and Title of Authorized Individual/Employer                                              Date

(b) __________________________________________________________________________________

    Print Name of Authorized Individual/Trustee                             City                         State

By __________________________________________________________________________________

    Signature and Title of Authorized Individual/Employer                                              Date

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Accepted for AXA Equitable		ACCEPTED FOR AXA EQUITABLE:
		_______________________________		By______________________________
(To be completed by the AXA Equitable Processing Office)		Print Name of Authorized Signatory		Signature of Authorized Signatory
		Effective Date: _______________
		Group Annuity Contract No. ____________
		A copy of the Contract, the Application, including Parts A and B (including the Contract Charges), and Investment Options Chart, will be signed by XXX Xxxxxxxxx and returned to the Contract Holder after review. All returned documents will govern the operation of the Contract. Initial Contributions will be accepted by AXA Equitable only after installation documents have been approved by AXA Equitable’s Processing Office.

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Attachment A - Investment Options Chart (Series 901)

Type B		Type A
AXA Conservative Allocation		Guaranteed Interest Option		Fidelity® VIP Contrafund®
AXA Conservative-Plus Allocation		All Asset Allocation		Fidelity® VIP Equity Income
EQ/Core Bond Index		American Century VP Mid Cap Value Fund		Fidelity VIP Mid Cap
EQ/Franklin Core Balanced		AXA Aggressive Allocation		Xxxxxxx Xxxxx VIT Mid Cap Value
EQ/Global Bond PLUS		AXA Moderate Allocation		Invesco V.I. Dividend Growth
EQ/Intermediate Government Bond Index		AXA Moderate-Plus Allocation		Invesco V.I. Global Real Estate
EQ/Money Market		AXA Tactical Manager 400		Invesco V.I. International Growth
EQ/PIMCO Ultra Short Bond		AXA Tactical Manager 500		Invesco V.I. Mid Cap Core Equity
EQ/Quality Bond PLUS		AXA Tactical Manager 2000		Invesco V.I. Small Cap Equity
Invesco V.I. High Yield		AXA Tactical Manager International		Ivy Funds VIP Energy
Ivy Funds VIP High Income		EQ/AllianceBernstein Small Cap Growth		Ivy Funds VIP Mid Cap Growth
Multimanager Core Bond		EQ/AXA Franklin Small Cap Value Core		Ivy Funds VIP Small Cap Growth
Multimanager Multi-Sector Bond		EQ/BlackRock Basic Value Equity		Lazard Retirement Emerging Markets Equity
PIMCO VIT CommodityRealReturn® Strategy		EQ/Boston Advisors Equity Income		MFS® International Value
		EQ/Xxxxxxx Socially Responsible		MFS® Investors Growth Stock
		EQ/Common Stock Index		MFS® Investors Trust
		EQ/Xxxxx New York Venture		MFS® Technology
		EQ/Equity 500 Index		MFS® Utilities
		EQ/Equity Growth PLUS		Multimanager Aggressive Equity
		EQ/Franklin Xxxxxxxxx Allocation		Multimanager International Equity
		EQ/GAMCO Small Company Value		Multimanager Large Cap Value
		EQ/Global Multi-Sector Equity		Multimanager Mid Cap Growth
		EQ/International Core PLUS		Multimanager Mid Cap Value
		EQ/International Equity Index		Multimanager Small Cap Growth
		EQ/International Value PLUS		Multimanager Small Cap Value
		EQ/JPMorgan Value Opportunities		Multimanager Technology
		EQ/Large Cap Core PLUS		Xxxxxxxxxxx Main Street Fund®/VA
		EQ/Large Cap Growth Index		Structured Investment Option
		EQ/Large Cap Growth PLUS		Target 2015 Allocation
		EQ/Large Cap Value Index		Target 2025 Allocation
		EQ/Large Cap Value PLUS		Target 2035 Allocation
		EQ/Lord Xxxxxx Large Cap Core		Target 2045 Allocation
		EQ/MFS International Growth		Xxxxxxxxx Global Bond Securities
		EQ/Mid Cap Index		Xxx Xxx VIP Global Hard Assets
		EQ/Mid Cap Value PLUS
		EQ/Xxxxxx & Xxxxxxxx Growth
		EQ/Xxxxxx Xxxxxxx Mid Cap Growth
		EQ/Mutual Large Cap Equity
		EQ/Xxxxxxxxxxx Global
		EQ/Small Company Index
		EQ/X. Xxxx Price Growth Stock
		EQ/Xxxxxxxxx Global Equity
		EQ/Xxx Xxxxxx Xxxxxxxx

2011 EV STRAT TSA - 901 Core (09/11)    16

Attachment B - ERISA Information

ERISA INFORMATION STATEMENT:

The U.S. Department of Labor has issued a class exemption (PTE 84-24) with respect to certain transactions involving insurance company products and employee benefit plans subject to ERISA. When applicable, the exemption requires that certain information be provided to the Plan and that the Employer or other appropriate fiduciary acknowledge receipt of the information and approve the transaction. AXA Equitable, AXA Network, LLC (“AXA Network”), AXA Advisors, LLC (“AXA Advisors”) and the Registered Representative(s) listed on the below are providing you with this Information Statement, even though this Information Statement may not be required under PTE 84-24 with respect to this transaction. AXA Network is a licensed insurance agency and AXA Advisors is a Registered Broker Dealer. Each is an affiliate of AXA Equitable. AXA Equitable has retained AXA Network as its general agent and AXA Advisors as its Broker Dealer to distribute AXA Equitable Life policies and contracts through the Registered Representatives. Each Registered Representative named is a licensed insurance agent of AXA Network and a Registered Representative of AXA Advisors and will receive compensation from AXA Network for the sale and servicing of your EQUI-VEST^® Contract. (“Servicing” does not include record keeping or administration of the Plan or Trust.) The maximum compensation payable by AXA Network to the Registered Representative on your EQUI-VEST Contract is shown on Attachment B. AXA Advisors and AXA Network both prohibit Registered Representatives from selling insurance products without first obtaining the consent of AXA Network or AXA Advisors.

Firm Name:

Please indicate the name(s) of the Registered Representative(s) of AXA Advisors or of a Broker/Dealer with which AXA Advisors or AXA Distributors has entered into a selling agreement, along with the Registered Representative’s Code Number:

Name		Code Number
_______________________________________________________________________		_____________________________
_______________________________________________________________________		_____________________________
_______________________________________________________________________		_____________________________
_______________________________________________________________________		_____________________________
_______________________________________________________________________		_____________________________
_______________________________________________________________________		_____________________________

2011 EV STRAT TSA - 901 Core (09/11)    17