COMPLETE APPLICATION FORM : JEE B.Ed.

- 2018

A - Registration Details
Registration Number : 20181004352

B - Personal Details
Candidate Name : JARINA BEGUM
Candidate Father Name : ABDUL GAFFAR
Candidate Mother Name : TABRUN NISHA
Candidate Date of Birth : 06/Jul/1989
Gender : Female
Category : OBC
Sub Category : Marital Status : Married
Certificate Number of SC/ST/OBC : 223173015796 State Domicile : UP
Nationality : Indian Specified Nationality :
Is Annual Family Income less than 2 Lac per annum ? : Yes
Differently Abled? : No Disability Type :
Disability Percentage : Is Zero Fees Required ? :
ID Proof : AADHAR CARD ID Number : 997049105226

C - Communication Address
Mobile Number : 9198131413 Alternate Mobile Number : 9506076540
Email Address : zaheerk82@gmail.com
Address Line 1 : H.NO 788
Address Line 2 : MOH LODHIPUR
Address Line 3 : SHAHJAHANPUR
State : Uttar Pradesh City : Shahjahanpur
Pincode : 242001

D - Permanent Address
Address Line 1 : H.NO 788
Address Line 2 : MOH LODHIPUR
Address Line 3 : SHAHJAHANPUR
State : Uttar Pradesh City : Shahjahanpur
Pincode : 242001
E - Opted Stream Details
Stream Opted for B.ED : Arts

F - SSC/ 10th Std/ Equivalent Details

Board Name : UP BOARD
Marks Obtained : 338 Maximum Marks : 600
Percentage : 56.33 Year Of Passing : 2007

G - Graduation Details
Have you completed Graduation ? : Appearing
Board Name : MJPR UNIVERSITY BAREILLY
Roll Number : 9995020008 Year Of Passing :
Marks Obtained : Maximum Marks :
Percentage : Expected Year Of Passing : 2018

H - Post Graduation Details

Have you completed Post Graduation ? :
Board Name :
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 or immersed or retired defense personnel No
or son/daughter of such personnel, or related to a disabled, missing
or dead defensive personnel as their son/daughter/wife :
E. Is your father or husband is serving in/retired from police or PAC or No
BSF or SSB or 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 : Bareilly Center Choice 2 : Lucknow
Center Choice 3 : Kanpur
K - Payment Details
Payment Transaction Number : LBP26119632655 Payment Receipt Number : 20180309
Payment Card Type : Other Cards Order Id : 2018100435220180309181115830
Payment Date : 09/Mar/2018 Amount : 1500

L - Declaration
• I, hereby, certify that the particulars given by me in this B.Ed. 2018-20 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 University of Lucknow for J.E.E. B.Ed. 2018-20 and undertake
to produce original documents whenever necessary.
• I will follow all instruction given by University of Lucknow in this regard.
• I understand all disputes will be subjected to territorial jurisdiction of Lucknow City only.