सं युत वे श परीा (मु य)

Joint Entrance Examination (Main)

JEE(Main)

APPLICATION NUMBER 240310404206

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) 230 WARD NO 12 ईमेल पता (Email Address) PATELSUMIT83056@GMAIL.COM
उप-थानीयता (Sub-
थानीयता (Locality) DEWAS CHANDANA
Locality)(Optional)
दे श कोड (Country Code) 91 दे श (Country) INDIA
राय (State) MADHYA PRADESH िजला (District) Dewas
वै किपक संपक सू (Alternate
मोबाइल नंबर (Mobile Number) 91 - 8305699694 NA
Contact No.) (Optional)
िपन कोड (Pin Code) 455001
थायी पता (Permanent Address)
पता (Premises No/ Name) 230 WARD NO 12 थानीयता (Locality) DEWAS
उप-थानीयता (Sub-
CHANDANA दे श (Country) INDIA
Locality)(Optional):
राय (State) MADHYA PRADESH िजला (District) Dewas
िपन कोड (Pin Code) 455001
यितगत योरा (PERSONAL DETAILS)
अयथी की जम ितिथ (Candidate's
अयथी का नाम (Candidate's Name) SUMIT PATEL 19-09-2005
Date of Birth)
िपता / अिभभावक का नाम (Father / माता / अिभभावक का नाम (Mother /
SANJAY PATEL NEETA PATEL
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 767898466120
Number)
PHOTOGRAPH
राय / केद शािसत दे श जहाँ से 12वीं /
समक उीण / उपिथत (State/ UT
MADHYA PRADESH े णी (Category ) OBC-(NCL) AS PER CENTRAL LIST
from where 12th/ Equivalent Passed/
Appearing)
या आपको मधुमेह ह  (Are You
NO िनवास की जगह ( Place of Residence ) 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 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 Of Exam Apply For)
िपता / अिभभावक यवसाय (Father / िपता / अिभभावक योयता (Father /
AGRICULTURE Matriculate
Guardian Occupation) Guardian Qualification)
माता / अिभभावक यवसाय (Mother / माता / अिभभावक योयता (Mother /
Not Applicable MATRICULATE
Guardian Occupation) Guardian Qualification)
परीा राय-पहला िवकप (Exam State परीा शहर-पहला िवकप (Exam City
MADHYA PRADESH INDORE
1st Choice ) 1st Choice )
परीा राय-दूसरा िवकप (Exam State परीा शहर-दूसरा िवकप (Exam City
MADHYA PRADESH UJJAIN
2nd Choice ) 2nd Choice )
परीा राय-तीसरा िवकप (Exam State परीा शहर-तीसरा िवकप (Exam City
MADHYA PRADESH BHOPAL
3rd Choice ) 3rd Choice )
परीा राय-चौथा िवकप (Exam State परीा शहर-चौथा िवकप (Exam City
MADHYA PRADESH JABALPUR
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 of
उीण की िथित (Pass Status) Passed 2022
Passing/Appearing)
योयता परीा (Qualifying Exam) 10 th or equivalent कू िलंग का थान (Place of Schooling) Urban
कू ल / कॉलेज का कार (Type of School / योयता परीा राय (Qualifying
Private Unaided MADHYA PRADESH
College) Examination State)
योयता परीा िजला (Qualifying MADHYA PRADESH BOARD OF
Dewas कू ल बोड (School Board)
Examination District) SECONDARY EDUCATION
का 10वीं की माकशीट/माणप के
govt shri narayan vidya
अनुसार िवालय/कॉलेज का नाम कू ल / कॉलेज का पता (School /
mandir hs excellence school dewas
(School/College name should be as per College Address)
no 02 dewas
Class 10th Mark sheet/certificate)
कू ल / कॉलेज िपनकोड (School / College रोल नंबर 10वीं माणप के अनुसार
455001 124643412
Pincode) (Roll number as per 10th certificate)
पिरणाम मोड (Result Mode) Percentage पूणा क (Total Marks) 500.0
ातांक (Obtain Marks) 433.0 ितशत (Percentage) 86.60
th
12वीं या समक योयता िववरण (12 or equivalent Qualification Details)
उीण / सिमिलत होने का वष (Year of
उीण की िथित (Pass Status) Appearing 2024
Passing/Appearing)
The final examination of
the 10+2 system, conducted
by any recognized Central/
State Board, such as the
Central Board of Secondary
योयता परीा (Qualifying Exam) कू िलंग का थान (Place of Schooling) Urban
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 MADHYA PRADESH
College) Examination State)
योयता परीा िजला (Qualifying MADHYA PRADESH BOARD OF
Dewas कू ल बोड (School Board)
Examination District) SECONDARY EDUCATION
का 12वीं की माकशीट/माणप के
अनुसार िवालय/कॉलेज का नाम prominent shiksha academy कू ल / कॉलेज का पता (School /
dewas
(School/College name should be as per dewas College Address)
Class 12th Mark sheet/certificate)
कू ल / कॉलेज िपनकोड (School / College रोल नंबर 12वीं माणप के अनुसार
455001 NA
Pincode) (Roll number as per 12th certificate)
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) 8962615182 ईमेल आईडी (Email ID) jkmponline@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) 164853107
लेन-दे न की ितिथ (Date of
परीा शु क (Exam Fee) 900.0 14-11-2023 16:10:42 PM
Transaction)
शु क जमा िकया गया (Fee Submitted
14-11-2023 16:09:45 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 : 106.201.248.0 Date of Downloading : 14-11-2023 16:11:46 PM