सं युत वे श परीा (मु य)

Joint Entrance Examination (Main)

JEE(Main)

APPLICATION NUMBER 240310066542

DO NOT SEND THIS PAGE TO NATIONAL TESTING AGENCY (NTA).
THE CANDIDATE IS REQUESTED TO RETAIN THE PRINTOUT OF THE CONFIRMATION PAGE FOR FUTURE REFERENCE.
यितगत योरा (Contact Details) वतमान पता (Present Address)
SHREE SARASWATI
पता (Premises No/ Name) ईमेल पता (Email Address) SHOUNAKDUTTA199@GMAIL.COM
CHS, B1-1304
CHEMBUR EAST, उप-थानीयता (Sub- NG ACHARYA MARG, NEAR ACHARYA
थानीयता (Locality)
MUMBAI Locality)(Optional) COLLEGE
दे श कोड (Country Code) 91 दे श (Country) INDIA
राय (State) MAHARASHTRA िजला (District) Mumbai
वै किपक संपक सू (Alternate
मोबाइल नंबर (Mobile Number) 91 - 8850905558 8898015977
Contact No.) (Optional)
िपन कोड (Pin Code) 400071
थायी पता (Permanent Address)
SHREE SARASWATI
पता (Premises No/ Name) थानीयता (Locality) CHEMBUR EAST, MUMBAI
CHS, B1-1304
NG ACHARYA MARG,
उप-थानीयता (Sub-
NEAR ACHARYA दे श (Country) INDIA
Locality)(Optional):
COLLEGE
राय (State) MAHARASHTRA िजला (District) Mumbai
िपन कोड (Pin Code) 400071
यितगत योरा (PERSONAL DETAILS)
अयथी की जम ितिथ (Candidate's
अयथी का नाम (Candidate's Name) SHOUNAK DUTTA 19-09-2005
Date of Birth)
िपता / अिभभावक का नाम (Father / माता / अिभभावक का नाम (Mother /
SAIKAT DUTTA SARBARI DUTTA
Guardian Name) Guardian Name)
िलंग (Gender) MALE राटीयता (Nationality ) INDIAN
ANY OTHER VALID
पहचान संया (Identification
पहचान के कार (Identity Type) GOVT IDENTITY WITH 901204467114
Number)
PHOTOGRAPH
राय / केद शािसत दे श जहाँ से 12वीं /
समक उीण / उपिथत (State/ UT
MAHARASHTRA े णी (Category ) GENERAL
from where 12th/ Equivalent Passed/
Appearing)
या आपको मधुमेह ह  (Are You िनवास की जगह ( Place of Residence
NO URBAN
Diabetic ? ) )
यिद आप एक Pwd उमीदवार ह , तो या
आपके पास ब चमाक िवकलांगता है (If you वािषक पािरवािरक आय ( Annual
NA 800000 AND ABOVE
are a Pwd Candidate, do you have Family Income )
benchmark disability)?
योयता परीा म कू ली िशा का
तैयारी का तरीका ( Mode of Preparation
Self-Study मायम ( Medium of schooling in English
)
qualifying exam )
परीा कद िववरण (Exam centre Details)
परीा के स के िलए आवे दन कर
के िलए आवे दन (Apply For) B.E./B.Tech Session 1 & Session 2
(Session Of Exam Apply For)
िपता / अिभभावक यवसाय (Father / िपता / अिभभावक योयता (Father /
PRIVATE SERVICE Post Graduate
Guardian Occupation) Guardian Qualification)
माता / अिभभावक यवसाय (Mother / माता / अिभभावक योयता (Mother /
Private Service GRADUATE
Guardian Occupation) Guardian Qualification)
परीा राय-पहला िवकप (Exam State परीा शहर-पहला िवकप (Exam
MAHARASHTRA MUMBAI/NAVI MUMBAI
1st Choice ) City 1st Choice )
परीा राय-दूसरा िवकप (Exam State परीा शहर-दूसरा िवकप (Exam City
MAHARASHTRA THANE
2nd Choice ) 2nd Choice )
परीा राय-तीसरा िवकप (Exam State परीा शहर-तीसरा िवकप (Exam
MAHARASHTRA RAIGAD
3rd Choice ) City 3rd Choice )
परीा राय-चौथा िवकप (Exam State परीा शहर-चौथा िवकप (Exam City
MAHARASHTRA PUNE
4th Choice ) 4th Choice )
न प मायम (Question Paper Medium) English
th
10वीं या समक योयता िववरण (10 or equivalent Qualification Details)
उीण / सिमिलत होने का वष (Year
उीण की िथित (Pass Status) Passed 2022
of Passing/Appearing)
कू िलंग का थान (Place of
योयता परीा (Qualifying Exam) 10 th or equivalent Urban
Schooling)
कू ल / कॉलेज का कार (Type of School योयता परीा राय (Qualifying
Private Unaided MAHARASHTRA
/ College) Examination State)
योयता परीा िजला (Qualifying COUNCIL FOR THE INDIAN SCHOOL
Mumbai कू ल बोड (School Board)
Examination District) CERTIFICATE EXAMINATIONS
का 10वीं की माकशीट/माणप के
अनुसार िवालय/कॉलेज का नाम कू ल / कॉलेज का पता (School / Mahul road, opposite RCF police station,
Ryan international school
(School/College name should be as College Address) chembur east
per Class 10th Mark sheet/certificate)
रोल नंबर 10वीं माणप के अनुसार
कू ल / कॉलेज िपनकोड (School / College
400071 (Roll number as per 10th 7520298
Pincode)
certificate)
पिरणाम मोड (Result Mode) Percentage पूणा क (Total Marks) 600.0
ातांक (Obtain Marks) 561.0 ितशत (Percentage) 93.50
th
12वीं या समक योयता िववरण (12 or equivalent Qualification Details)
उीण / सिमिलत होने का वष (Year
उीण की िथित (Pass Status) Appearing 2024
of Passing/Appearing)
The final examination of
the 10+2 system,
conducted by any
recognized Central/ State
Board, such as the Central
कू िलंग का थान (Place of
योयता परीा (Qualifying Exam) Board of Secondary Urban
Schooling)
Education, New Delhi;
Council for the Indian
School Certificate
Examinations, New Delhi
etc.
कू ल / कॉलेज का कार (Type of School योयता परीा राय (Qualifying
Private Unaided MAHARASHTRA
/ College) Examination State)
योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY
Raigad कू ल बोड (School Board)
Examination District) EDUCATION
का 12वीं की माकशीट/माणप के
अनुसार िवालय/कॉलेज का नाम कू ल / कॉलेज का पता (School /
Yak public school Hal budruk, po khalapur, khopoli
(School/College name should be as College Address)
per Class 12th Mark sheet/certificate)
रोल नंबर 12वीं माणप के अनुसार
कू ल / कॉलेज िपनकोड (School / College
410202 (Roll number as per 12th NA
Pincode)
certificate)
अितिरत जानकािरयां (Additional Details)
या आप जु ड़वा ह और दोनों जे ईई (मे न) - 2024 के िलए आवे दन कर रहे
NO
ह (Are you a Twin and both applying for JEE (MAIN) – 2024)?
आपातकालीन संपक िववरण प (Emergency Contact Details)
दे श (Country) INDIA दे श कोड (Country Code) +91
मोबाइल नंबर (Mobile Number) 9619191796 ईमेल आईडी (Email ID) sd.kolkata@gmail.com
उमीदवार ारा अपलोड की गई छिवयां (IMAGES UPLOADED BY THE CANDIDATE)

PHOTO

SIGNATURE
शु क भु गतान िववरण (Fee Payment Details)
भु गतान का कार (Payment Mode) Online लेन-दे न आईडी (Transaction ID) 159355646
लेन-दे न की ितिथ (Date of
परीा शु क (Exam Fee) 2000.0 06-11-2023 22:51:03 PM
Transaction)
शु क जमा िकया गया (Fee Submitted
06-11-2023 22:49:57 PM
On)
घोषणा (Declaration)
I declare that information furnished by me in the application form is true in all respect and nothing is concealed. In case any entry or information is found to
be false, this shall entail automatic cancellation of my admission besides rendering me liable to such actions as deemed fit by the University. I hereby
undertake that I have carefully gone through the eligibility conditions prescribed in the prospectus for the programme. I am applying after satisfying that I
meet the eligibility conditions. If at any stage it is found that I do not fullfill the minimum prescribed criteria, my admission, if granted, shall stand cancelled
and I shall have no right to admission whatsoever.
IP Address : 49.43.25.37 Date of Downloading : 06-11-2023 22:51:36 PM