COMPLETE APPLICATION FORM : JEE B.Ed.

- 2019

A - Registration Details
Registration number : 20191177792

B - Personal Details
Candidate Name : KM MADHURI TRIPATHI
Candidate Father Name : PREM NARAYAN TRIPATHI
Candidate Mother Name : PREM LATA TRIPATHI
Candidate Date of Birth : 07/Aug/1994
Gender : Female
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 ? : Yes Is Zero Fees required ? :
Is annual family income less than 2 lac pa ? : Sub category :
Differently abled ? : No Disability type : https://www.tcsion.com/EForms/images/online
Disability percentage : ID proof : Aadhar Card
ID number : 565821648287

C - Communication Address
Mobile number : 9140774796 Alternate mobile number : 9670334104
Email address : rp8679449@gmail.com
Address line 1 : BANDHA
Address line 2 : SHIKAR GARH
Address line 3 : BRIDGEMANGANJ MAHARAJGANJ
State : Uttar Pradesh City : Maharajganj
Pincode : 273157

D - Permanent Address
Address line 1 : BANDHA
Address line 2 : SHIKAR GARH
Address line 3 : BRIDGEMANGANJ MAHARAJGANJ
State : Uttar Pradesh City : Maharajganj
Pincode : 273157
E - Opted Stream Details
Stream opted for B.Ed. : Arts

F - SSC/ 10th Std/ Equivalent Details

Board name : UP BOARD ALLAHABAD
Marks obtained : 371 Maximum marks : 600
Percentage : 61.83 Year of passing : 2009

G - Graduation Details
Have you completed Graduation ? : Pass
Stream of Graduation : Arts Have you done B.E. / B.Tech? https://www.tcsion.com/EForms/i
Name of University/Institution : DDUGU GORAKHPUR
Roll number : 7113210063 Year of passing : 2014
Marks obtained : 1021 Maximum marks : 1800
Percentage : 56.72 Expected year of passing : https://www.tcsion.com/EForms/ima

H - Post Graduation Details

Have you completed Post Graduation ? :
Name of University/Institution :
Roll number : Year of passing : https://www.tcsion.com/EForms/ima
Marks obtained : Maximum marks :
Percentage : Expected year of passing : https://www.tcsion.com/EForms/imag

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 : https://www.tcsion.com/EForms/images/onlineAppForm/form59873/ba
A.2. In the team items by the Candidate : https://www.tcsion.com/EForms/images/onlineAppForm/form59873/ba
A.3. In other college tournaments or sports or
https://www.tcsion.com/EForms/images/onlineAppForm/form59873/ba
sportscompetitions run by a university :
B. Candidates of National Cadet Corps and https://www.tcsion.com/EForms/images/onlineAppForm/form59873/banner
National Service Scheme : Image.png

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 : Gorakhpur Center choice 2 : Lucknow
Center choice 3 : Prayagraj
K - Payment Details
Transaction number : 729886742 Receipt number : 0164425612
Payment status : Success Order id : 2019117779220190301171421463
Payment date : 01/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.