सं युत वे श परीा (मु य)

Joint Entrance Examination (Main)

JEE(Main)

APPLICATION NUMBER 240310224814

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)
पता (Premises No/ Name) TALWAL ईमेल पता (Email Address) AKANKSHAM1739@GMAIL.COM
उप-थानीयता (Sub-
थानीयता (Locality) TALWAL TALWAL
Locality)(Optional)
दे श कोड (Country Code) 91 दे श (Country) INDIA
राय (State) UTTAR PRADESH िजला (District) Ghazipur
वै किपक संपक सू (Alternate
मोबाइल नंबर (Mobile Number) 91 - 9131406001 9129281235
Contact No.) (Optional)
िपन कोड (Pin Code) 233001
थायी पता (Permanent Address)
पता (Premises No/ Name) TALWAL थानीयता (Locality) TALWAL
उप-थानीयता (Sub-
TALWAL दे श (Country) INDIA
Locality)(Optional):
राय (State) UTTAR PRADESH िजला (District) Ghazipur
िपन कोड (Pin Code) 233001
यितगत योरा (PERSONAL DETAILS)
अयथी की जम ितिथ (Candidate's
अयथी का नाम (Candidate's Name) AKANKSHA MAURYA 20-06-2004
Date of Birth)
िपता / अिभभावक का नाम (Father / BHAGWAN SINGH माता / अिभभावक का नाम (Mother /
MANTRA SINGH KUSHWAHA
Guardian Name) KUSHWAHA Guardian Name)
िलंग (Gender) FEMALE राटीयता (Nationality ) INDIAN
ANY OTHER VALID GOVT
पहचान संया (Identification
पहचान के कार (Identity Type) IDENTITY WITH 385319330437
Number)
PHOTOGRAPH
राय / केद शािसत दे श जहाँ से 12वीं /
समक उीण / उपिथत (State/ UT
CHHATTISGARH े णी (Category ) OBC-(NCL) AS PER CENTRAL LIST
from where 12th/ Equivalent Passed/
Appearing)
या आपको मधुमेह ह  (Are You िनवास की जगह ( Place of Residence
NO RURAL
Diabetic ? ) )
यिद आप एक Pwd उमीदवार ह , तो या
आपके पास ब चमाक िवकलांगता है (If you वािषक पािरवािरक आय ( Annual
NA 0-100000
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 /
AGRICULTURE Not Applicable
Guardian Occupation) Guardian Qualification)
माता / अिभभावक यवसाय (Mother / माता / अिभभावक योयता (Mother /
Others NOT APPLICABLE
Guardian Occupation) Guardian Qualification)
परीा राय-पहला िवकप (Exam State परीा शहर-पहला िवकप (Exam
UTTAR PRADESH GHAZIPUR
1st Choice ) City 1st Choice )
परीा राय-दूसरा िवकप (Exam State परीा शहर-दूसरा िवकप (Exam City
UTTAR PRADESH VARANASI
2nd Choice ) 2nd Choice )
परीा राय-तीसरा िवकप (Exam State परीा शहर-तीसरा िवकप (Exam
UTTAR PRADESH MAU
3rd Choice ) City 3rd Choice )
परीा राय-चौथा िवकप (Exam State परीा शहर-चौथा िवकप (Exam City
UTTAR PRADESH GORAKHPUR
4th Choice ) 4th Choice )
न प मायम (Question Paper Medium) English
10वीं या समक योयता िववरण (10th or equivalent Qualification Details)
उीण / सिमिलत होने का वष (Year
उीण की िथित (Pass Status) Passed 2020
of Passing/Appearing)
कू िलंग का थान (Place of
योयता परीा (Qualifying Exam) 10 th or equivalent Rural
Schooling)
कू ल / कॉलेज का कार (Type of School योयता परीा राय (Qualifying
Government Aided Private CHHATTISGARH
/ College) Examination State)
योयता परीा िजला (Qualifying CHHATISGARH BOARD OF
Balodabazar-Bhatapara कू ल बोड (School Board)
Examination District) SECONDARY EDUCATION
का 10वीं की माकशीट/माणप के
shri shankaracharya
अनुसार िवालय/कॉलेज का नाम कू ल / कॉलेज का पता (School /
VIDYAPEETH DABADIH ( Dabadih ( Baloda BAZAR )
(School/College name should be as College Address)
Baloda BAZAR )
per Class 10th Mark sheet/certificate)
रोल नंबर 10वीं माणप के अनुसार
कू ल / कॉलेज िपनकोड (School / College
493332 (Roll number as per 10th 1201105884
Pincode)
certificate)
पिरणाम मोड (Result Mode) Percentage पूणा क (Total Marks) 600.0
ातांक (Obtain Marks) 527.0 ितशत (Percentage) 87.83
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) Passed 2022
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 Rural
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
Government Aided Private CHHATTISGARH
/ College) Examination State)
योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY
Balodabazar-Bhatapara कू ल बोड (School Board)
Examination District) EDUCATION
का 12वीं की माकशीट/माणप के
Shri shankaracharya
अनुसार िवालय/कॉलेज का नाम कू ल / कॉलेज का पता (School /
VIDYAPEETH H S Dabadih
(School/College name should be as College Address)
SCHOOL DABADIH
per Class 12th Mark sheet/certificate)
रोल नंबर 12वीं माणप के अनुसार
कू ल / कॉलेज िपनकोड (School / College
493332 (Roll number as per 12th 2221117334
Pincode)
certificate)
पिरणाम मोड (Result Mode) Percentage पूणा क (Total Marks) 500.0
ातांक (Obtain Marks) 423.0 ितशत (Percentage) 84.60
अितिरत जानकािरयां (Additional Details)
या आप जु ड़वा ह और दोनों जे ईई (मे न) - 2024 के िलए आवे दन कर रहे ह
NO
(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) 9129281236 ईमेल आईडी (Email ID) anupamsingh235@gmail.com
उमीदवार ारा अपलोड की गई छिवयां (IMAGES UPLOADED BY THE CANDIDATE)

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शु क भु गतान िववरण (Fee Payment Details)

भु गतान का कार (Payment Mode) Online लेन-दे न आईडी (Transaction ID) CPADGMOKC5
 लेन-दे न की ितिथ (Date of
परीा शु क (Exam Fee) 1600.0 01-01-1900 00:00:00 AM
Transaction)
शु क जमा िकया गया (Fee Submitted
17-11-2023 10:44:43 AM
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 : 49.36.182.178 Date of Downloading : 17-11-2023 22:13:50 PM