सं युत वे श परीा (मु य)

Joint Entrance Examination (Main)

JEE(Main)

APPLICATION NUMBER 240310014874

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)
NARAYANPUR,
पता (Premises No/ Name) ईमेल पता (Email Address) STUDENTAVINASH10@GMAIL.COM
MIRZAPUR
उप-थानीयता (Sub-
थानीयता (Locality) MIRZAPUR NA
Locality)(Optional)
दे श कोड (Country Code) 91 दे श (Country) INDIA
राय (State) UTTAR PRADESH िजला (District) Mirzapur
वै किपक संपक सू (Alternate
मोबाइल नंबर (Mobile Number) 91 - 6388787828 9170460440
Contact No.) (Optional)
िपन कोड (Pin Code) 231305
थायी पता (Permanent Address)
NARAYANPUR,
पता (Premises No/ Name) थानीयता (Locality) MIRZAPUR
MIRZAPUR
उप-थानीयता (Sub-
NA दे श (Country) INDIA
Locality)(Optional):
राय (State) UTTAR PRADESH िजला (District) Mirzapur
िपन कोड (Pin Code) 231305
यितगत योरा (PERSONAL DETAILS)
अयथी की जम ितिथ (Candidate's
अयथी का नाम (Candidate's Name) AVINASH 16-09-2006
Date of Birth)
िपता / अिभभावक का नाम (Father / माता / अिभभावक का नाम (Mother /
KAMLESH AARTI
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 204352391786
Number)
PHOTOGRAPH
राय / केद शािसत दे श जहाँ से 12वीं /
समक उीण / उपिथत (State/ UT
UTTAR PRADESH े 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 300001-400000
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
Online Coaching 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 / GOVERNMENT िपता / अिभभावक योयता (Father /
Graduate
Guardian Occupation) SERVICE Guardian Qualification)
माता / अिभभावक यवसाय (Mother / माता / अिभभावक योयता (Mother /
Others OTHERS
Guardian Occupation) Guardian Qualification)
परीा राय-पहला िवकप (Exam State परीा शहर-पहला िवकप (Exam
UTTAR PRADESH VARANASI
1st Choice ) City 1st Choice )
परीा राय-दूसरा िवकप (Exam State परीा शहर-दूसरा िवकप (Exam City
UTTAR PRADESH ALLAHABAD/PRAYAGRAJ
2nd Choice ) 2nd Choice )
परीा राय-तीसरा िवकप (Exam State परीा शहर-तीसरा िवकप (Exam
UTTAR PRADESH CHANDAULI
3rd Choice ) City 3rd Choice )
परीा राय-चौथा िवकप (Exam State परीा शहर-चौथा िवकप (Exam
UTTAR PRADESH LUCKNOW
4th Choice ) City 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 UTTAR PRADESH
/ College) Examination State)
योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY
Varanasi कू ल बोड (School Board)
Examination District) EDUCATION
का 10वीं की माकशीट/माणप के SWAI HARSEWANAND
अनुसार िवालय/कॉलेज का नाम PUB SCH कू ल / कॉलेज का पता (School /
GHARHWAGHAT VARANASI
(School/College name should be as GARHWAGHAT College Address)
per Class 10th Mark sheet/certificate) VARANASI
रोल नंबर 10वीं माणप के अनुसार
कू ल / कॉलेज िपनकोड (School / College
71323 (Roll number as per 10th 23274461
Pincode)
certificate)
पिरणाम मोड (Result Mode) Percentage पूणा क (Total Marks) 500.0
ातांक (Obtain Marks) 365.0 ितशत (Percentage) 73.00
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 UTTAR PRADESH
/ College) Examination State)
योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY
Varanasi कू ल बोड (School Board)
Examination District) EDUCATION
का 12वीं की माकशीट/माणप के SWAMI
अनुसार िवालय/कॉलेज का नाम HARSEWANAND PUB कू ल / कॉलेज का पता (School /
GARHWAGHAT VARANASI
(School/College name should be as SCH GARHWAGHAT College Address)
per Class 12th Mark sheet/certificate) VARANASI
रोल नंबर 12वीं माणप के अनुसार
कू ल / कॉलेज िपनकोड (School / College
71323 (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) 9984085292 ईमेल आईडी (Email ID) avinashyadav661980@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) CPADFSENI8
 लेन-दे न की ितिथ (Date of
परीा शु क (Exam Fee) 1800.0 05-11-2023 17:05:01 PM
Transaction)
शु क जमा िकया गया (Fee Submitted
05-11-2023 17:04:45 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 : 103.15.252.89 Date of Downloading : 05-11-2023 17:08:55 PM