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JEE (Advanced) Copy

Registration No.

INDIAN INSTITUTES OF TECHNOLOGY


JOINT ENTRANCE EXAMINATION (Advanced) - 2013

JEE (Advanced) - 2013

Auth Code: 6078261f0ba90256908a9004d73ecaff


1. Candidate Name: Jadhav Pallavi Ashok
2. Father Name: Jadhav Ashok Laxman
3. Date of Birth: 15-04-1995

4. Category: SC

5. Gender: FEMALE

6. Nationality: INDIAN

7. Year of Passing QE: 2013

8. Board of QE: Maharastra State Board of Secondary


and Higher Secondary Education

9. First Attempt at JEE: 2013

10. Entitled for DS Seat: NO

I. PUNE (108)
11. Choice of
Exam Cities: II. NAGPUR (106)
III. MUMBAI (105)

13. Physically Disabled: NO

14. Scribe Required: NO

15. Email: pjadhav624@gmail.com

16. Landline No: null

17. Mobile No: 9421474298, 9421474298

18. Address: gopikishan nagar


gopikishan nagar
gopikishan nagar

PASTE RECENT
COLOR PHOTOGRAPH
HERE

3.5 cm x 4.5 cm
with the face
covering about
75% of the photo

19. PIN Code: 431203

D15210031

12. Question Paper Language: ENGLISH

DECLARATION BY THE CANDIDATE


I hereby declare that all the particulars stated in this registration form are true to the best of my knowledge and belief. I have read JEE
(Advanced) - 2013 Information Brochure (given on JEE (Advanced) Website) and I shall abide by the terms and conditions therein. I also
certify that I have not appeared in JEE in 2011 or earlier and neither taken admission nor paid the registration fee at any of the IITs / ISMDhanbad. In the event of suppression or distortion of any fact regarding the eligibility criteria, category, nationality etc., in my registration
form, I understand that I will be denied the opportunity to appear in JEE (Advanced) - 2013 and if already admitted, my admission / degree
acquired is liable for cancellation. I also understand that the decision of the Joint Admission Board regarding my admission to IITs / ISMDhanbad is final and I shall abide by the decision. Further, if admitted, I promise to abide by the rules and norms of discipline of the
Institute I join.

Place : ......................

Candidate Signature (Sign within the box only)

Date : ........................
Name of Parent/Guardian: ..............................................................................

(Signature of the Candidate)

(Countersigned by Parent/Guardian)

JEE (Advanced) - 2013

BY REGISTERED POST / SPEED POST ONLY

Indian Institutes of Technology


Registration No.

Your Choice of
Examination
Cities

Choice - I

Choice - II

Choice - III

108

106

105

REGISTRATION NO :

D15210031
D15210031

From:

To:

Name: Jadhav Pallavi Ashok

The Chairman
Joint Entrance Examination (Advanced) - 2013
Indian Institute of Technology Bombay
Powai
Mumbai
PIN Code: 400076

Address:
gopikishan nagar
gopikishan nagar
gopikishan nagar
PIN Code: 431203
Landline No: null
Mobile No: 9421474298, 9421474298
Email: pjadhav624@gmail.com

CUT HERE AND PASTE THE UPPER PART ON A5 ENVELOPE

PLEASE INSERT THE REGISTRATION FORM IN THE ENVELOPE IN SUCH


MANNER THAT THE BARCODE ON THE REGISTRATION FORM IS NOT
FOLDED.
CHECKLIST FOR THE CANDIDATE
1. Tick the box if you have enclosed the following documents:
a. Completed Registration Form with your and parent / guardian's signature.
b. Your colour photograph (of size 3.5 cm x 4.5 cm) affixed on Registration Form appropriately.
c. Attested Copy of Proof of Date of Birth.
d. Attested copy of category certificate if you belong to SC/ST/OBC(NCL)/PwD.
e. Request letter of provision of Scribe (PwD only).

2. Retain a photocopy of the completed registration form with you for future reference.
3. Send your registration form to the IIT as mentioned on the address slip by 20th May 2013.