Form Name BTech - (General)

Application Number 122102211

Applicant Details
Name ABHIJEET ANAND JHA
Gender MALE Date of Birth 30/01/2005 Nationality INDIA
Mobile Number +91-9313977826 Email ID ABHIJEETANANDJHA01@GMAIL.COM

Category Details
Category GENERAL Sub Category GENERAL

Program Details
Program Level UNDER GRADUATION - UG Stream ENGINEERING
Course BTECH
Tentative Test Center Location DELHI

Parent Or Guardian Details For Communication

Full Name PRAVIN KUMAR JHA Email ID PRAVINJHA01@GMAIL.COM
Earning member of your
Mobile Number +91-9971736475 FATHER ONLY
family

Address Details
L-49, 3RD FLOOR, SRI NIWASPURI, NEW DELHI
City NEW DELHI State DELHI Country INDIA Pincode 110065

Payment Details
Transaction No 4077501 Payment Mode Online
Date 14/01/2022 Amount in Rs. 2000

Declaration

• I hereby confirm that the above-mentioned details are correct.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 and understood all provisions of admissions and
agree to abide by them. I also affirm that I fulfil the eligibility requirements for the program(s) applied. I understand that I can
only apply once for each group. In case I apply more than once, only one of my application will be accepted and the
application and entrance test fees remitted will not be refunded.

• If it is found at a later stage, during active verification, that I have given false or incorrect or untrue information w.r.t
educational qualification, marks, nationality etc., or submitted an eligibility document from the unrecognized board or
university, my admission or degree will be cancelled without any notice, with forfeiture of all the fee paid.

• Jurisdiction for dispute if any shall be at Udupi Court, Karnataka, India only.