4. Date of Birth (Must be born on or after 01 Oct, 2000) (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

10. Defence / Paramilitary Personnel / Martyrs Ward (son/daughter) [ Yes/No] 11. Person with disability (Y/N)

# Applicable only when passed 10+2 exam from Himachal Pradesh.

1. Name of Candidate

2. Father’s Name

3. Mother’s Name

12. Details of Qualifying exam (10+2 or equivalent) : 13. Religion (i.e. Hindu/Muslim/Sikh/Jain/Christian/Other)

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

14. Details of JEE Exam - 2021

JEE Application No. JEE (Main) Roll No. Paper-1 JEE (Main) Roll No. Paper-3

JEE (Main) Roll No. Paper-2 JEE (Main) Roll No. Paper-4

15. Permanent Home address

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

17. 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/2021/WS/…..................…….

APPLICATION FORM - 2021 (FOR ADMISSION THROUGH JEE-2021 RANKING)

AB Road, Raghogarh, Guna (M.P.)

JAYPEE UNIVERSITY OF ENGINEERING & TECHNOLOGY

A -10, Sector - 62, Noida - 201309 (U.P.)

Waknaghat, Distt-solan - 173 234 (H.P.)

JAYPEE UNIVERSITY OF INFORMATION TECHNOLOGY

JAYPEE INSTITUTE OF INFORMATION TECHNOLOGY

Paste Passport Size Colour Photo

19. 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

20. Attachments

l Copy of JEE Main 2021 Admit Cards/Score Cards.

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.

21. 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 and if already admitted, my admission would stand cancelled. I also understand that the decision of JIIT/JUIT/JUET 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

18. 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

CODES FOR THE STATES

CODE

STATE

1

ANDHRA PRADESH

2

ARUNACHAL PRADESH

3

ASSAM

4

BIHAR

5

CHHATTISGARH

6

GOA

7

GUJARAT

8

HARYANA

9

HIMACHAL PRADESH

10

JHARKHAND

11

KARNATAKA

12

KERALA

13

MADHYA PRADESH

14

MAHARASHTRA

15

MANIPUR

16

MEGHALAYA

17 MIZORAM

18 NAGALAND 19 ORISSA 20 PUNJAB 21

RAJASTHAN

22

SIKKIM

23

TAMILNADU 24

TELANGANA

25

TRIPURA

26

UTTAR PRADESH

27

UTTARAKHAND

28

WEST BENGAL

UNION TERRITORIES:

29

ANDAMAN AND NICOBAR

30

CHANDIGARH

31

DADRA NAGAR HAVELI

32

DAMANDIU

33

JAMMU AND KASHMIR

34

LAKSHADWEEP

35

LADAKH

36

DELHI

37

PUDUCHERRY