1. Name of Candidate

2. Father’s Name

3. Mother’s Name

4. Date of Birth (Must be born on or after 01 Oct, 1998) (DD/MM/YYYY)

5. Nationality 6. Gender (M/F/TG) 7. Category (Tick ) Gen SC ST OBC

#8. HP Category for JUIT, Waknaghat only [Fill Yes/No ] 9. Aadhaar No. of Candidate # Applicable only when passed 10+2 exam from Himachal Pradesh.

10. Details of Qualifying exam (10+2 or equivalent) : 11. Religion (i.e. Hindu/Muslim/Sikh/Jain/Christian/Other)

Name of School City/Distt. of School State of School Board Year of Passing

12. Details of JEE Exam - 2019

JEE Application No. JEE (Main) Roll No.

13. Permanent Home address

14. Current Correspondence address (Fill- ‘SAME’ if your correspondence address is same as your permanent address)

15. Contact Details:

Mobile No. Land Line No.

E-mail ID

DistrictState Code

(See list on Reverse)PIN Code

APPLICATION FORM - 2019 (FOR ADMISSION THROUGH JEE-2019 RANKING)

PLEASE FILL ALL DETAILS IN CAPITAL LETTERS ONLY (ALL FIELDS ARE MANDATORY)

Cond...Page2

DistrictState Code

(See list on Reverse)PIN Code

Application No. JEEbased/2019/WS/…..................…….

APPLICATION FORM - 2019 (FOR ADMISSION THROUGH JEE-2019 RANKING)

JAYPEE INSTITUTE OF INFORMATION TECHNOLOGY A -10, Sector - 62, Noida - 201309 (U.P.)

JAYPEE UNIVERSITY OF INFORMATION TECHNOLOGYWaknaghat, Distt-solan - 173 215 (H.P.)

JAYPEE UNIVERSITY OF ENGINEERING & TECHNOLOGYAB Road, Raghogarh, Guna (M.P.)

JAYPEE UNIVERSITY ANOOPSHAHRAnoopshahr, Bulandshahr (U.P.)

Paste Passport Size Colour Photo

16. Demand Draft Details: (Not applicable in case form is purchased on payment on cash or by post from Institutional Counter)

DD No. Dated Amount (Rs.) 1 2 00/-

Bank

17. Bank Details: (Required for Refund in case of Withdrawal) (ONLY PARENT/SELF)

Name of Account Holder Bank Name

Account Number Branch Name

Address of Bank IFSC Code

18 Attachments

l Copy of JEE Main 2019 Admit Card/Score Card.

l Bank draft of Rs. 1200/- in case of downloaded application form from the website. Draft should be made in favor of Jaypee Institutes Admission Account, payable at Noida/Delhi.

19. Declaration by the Student:1. I, hereby declare that all the particulars stated in this application form are true to the best of my knowledge and belief. I have read the Information

Brochure and the Admission procedure and I shall abide by them. In the event of suppression or distortion of any fact like date of birth, category etc. made in my application form, I understand that I will be denied the opportunity to be admitted to JIIT/JUIT/JUET/JUA and if already admitted, my admission would stand cancelled. I also understand that the decision of JIIT/JUIT/JUET/JUA regarding my admission will be final and binding on me.

2. I am aware of Universities approach toward ragging and the punishment to which I am liable if found guilty of ragging.

SIGNATURE OF PARENT SIGNATURE OF CANDIDATE