COMPLETE APPLICATION FORM : JEE B.Ed.

- 2019

A - Registration Details
Registration number : 20191581867

B - Personal Details
Candidate Name : DEEPAK PANDEY
Candidate Father Name : GAURI SHANKAR PANDEY
Candidate Mother Name : LAXMI DEVI
Candidate Date of Birth : 20/May/1998
Gender : Male
Marital status : Unmarried
Nationality : Indian Specified nationality :
State domicile : UP 10th passed from UP : Yes
12th/Equivalent passed from UP : Yes Graduation passed/pursuing final year from UP : Yes
Category : General Caste Certificate No of SC/ST/OBC :
Do you belong to Economically Weaker Section ? : No Is Zero Fees required ? :
Is annual family income less than 2 lac pa ? : Sub category :
Differently abled ? : No Disability type :
Disability percentage : ID proof : Aadhar Card
ID number : 751199492239

C - Communication Address
Mobile number : 8126877386 Alternate mobile number : 8279463117
Email address : pky96783@gmail.com
Address line 1 : VILL POST SAHAN
Address line 2 : DIST MAINPURI
Address line 3 : MAINPURI
State : Uttar Pradesh City : Mainpuri
Pincode : 205001

D - Permanent Address
Address line 1 : VILL POST SAHAN
Address line 2 : DIST MAINPURI
Address line 3 : MAINPURI
State : Uttar Pradesh City : Mainpuri
Pincode : 205001
E - Opted Stream Details
Stream opted for B.Ed. : Arts

F - SSC/ 10th Std/ Equivalent Details

Board name : UP MADHYAMIK SANSKRIT SHIKSHA PARISHAD LUCKNOW
Marks obtained : 321 Maximum marks : 500
Percentage : 64.2 Year of passing : 2014

G - Graduation Details
Have you completed Graduation ? : Appearing
Stream of Graduation : Arts Have you done B.E. / B.Tech?
Name of University/Institution : SAMPURNANAND SANSKRIT VISHWAVIDHYALAYA VARANASHI
Roll number : 18225681 Year of passing :
Marks obtained : Maximum marks :
Percentage : Expected year of passing : 2019

H - Post Graduation Details

Have you completed Post Graduation ? :
Name of University/Institution :
Roll number : Year of passing :
Marks obtained : Maximum marks :
Percentage : Expected year of passing :

I - Weightage Details
A. Have you participated in National or State level or Inter University
No
Sports Competition ? :
A.1. In the individual items by the Candidate :
A.2. In the team items by the Candidate :
A.3. In other college tournaments or sports or
sportscompetitions run by a university :
B. Candidates of National Cadet Corps and
National Service Scheme :

C. Do you need reservation of dependents of freedom fighters? : No

D. Are you in active service/immersed/retired defense personnel or son/daughter of such personnel,
or related to a disabled, missing or dead defensive personnel as their son/daughter/wife : No
E. Is your father or husband is serving in/retired from police or PAC or BSF or SSB or
No
ITBP or CRPF or service in home guards or disabled/dead in such services :
F. Female Candidate who is Widowed, Divorced or Abandoned
(i.e. Candidate has to submit the Certificate of Law) :

J - Center Details
Center choice 1 : Agra Center choice 2 : Kanpur
Center choice 3 : Lucknow
K - Payment Details
Transaction number : 738792095 Receipt number : IGAFPLSQK1
Payment status : Success Order id : 2019158186720190311143735069
Payment date : 11/Mar/2019 Amount : 1500

L - Declaration
• I, hereby, certify that the particulars given by me in this B.Ed. 2019-21 online application form are true to best of my
knowledge and belief, for any mismatch or incorrect information, only I will be responsible.
• I also certify that I fulfill the eligibility criteria laid down by M.J.P. ROHILKHAND UNIVERSITY, BAREILLY for J.E.E.
B.Ed. 2019-21 and undertake to produce original documents whenever necessary.
• I will follow all instruction given by M.J.P. ROHILKHAND UNIVERSITY, BAREILLY in this regard.
• I understand all disputes will be subjected to territorial jurisdiction of BAREILLY city only.