सं युत वे श परीा (मु य)

Joint Entrance Examination (Main)

JEE(Main)

APPLICATION NUMBER 240310480856

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)
C-29 IFFCO TOWNSHIP
पता (Premises No/ Name) ईमेल पता (Email Address) SURESHPATNAIK7226@GMAIL.COM
PARADEEP
उप-थानीयता (Sub-
थानीयता (Locality) PARADEEP NA
Locality)(Optional)
दे श कोड (Country Code) +91 दे श (Country) INDIA
राय (State) ODISHA िजला (District) Jagatsinghapur
वै किपक संपक सू (Alternate
मोबाइल नंबर (Mobile Number) +91 - 9437101309 9438617689
Contact No.) (Optional)
िपन कोड (Pin Code) 754142
थायी पता (Permanent Address)
C-29 IFFCO TOWNSHIP
पता (Premises No/ Name) थानीयता (Locality) PARADEEP
PARADEEP
उप-थानीयता (Sub-
NA दे श (Country) INDIA
Locality)(Optional):
राय (State) ODISHA िजला (District) Jagatsinghapur
िपन कोड (Pin Code) 754142
यितगत योरा (PERSONAL DETAILS)
अयथी की जम ितिथ (Candidate's
अयथी का नाम (Candidate's Name) SURESH PATNAIK 19-08-2005
Date of Birth)
िपता / अिभभावक का नाम (Father / RANJAN KUMAR माता / अिभभावक का नाम (Mother /
SONI PATNAIK
Guardian Name) PATNAIK Guardian Name)
िलंग (Gender) MALE राटीयता (Nationality ) INDIAN
BANK PASSBOOK पहचान संया (Identification
पहचान के कार (Identity Type) 184001000007708
WITH PHOTOGRAPH Number)
राय / केद शािसत दे श जहाँ से 12वीं /
समक उीण / उपिथत (State/ UT
ODISHA े णी (Category ) GENERAL
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 वािषक पािरवािरक आय ( Annual
NA 800000 AND ABOVE
you are a Pwd Candidate, do you Family Income )
have 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 / िपता / अिभभावक योयता (Father /
ENGINEERING Graduate
Guardian Occupation) Guardian Qualification)
माता / अिभभावक यवसाय (Mother / माता / अिभभावक योयता (Mother /
Not Applicable GRADUATE
Guardian Occupation) Guardian Qualification)
परीा राय-पहला िवकप (Exam State परीा शहर-पहला िवकप (Exam
ODISHA JAGATSINGHPUR
1st Choice ) City 1st Choice )
परीा राय-दूसरा िवकप (Exam State परीा शहर-दूसरा िवकप (Exam
ODISHA KENDRAPARA
2nd Choice ) City 2nd Choice )
परीा राय-तीसरा िवकप (Exam परीा शहर-तीसरा िवकप (Exam
ODISHA BHUBANESWAR
State 3rd Choice ) City 3rd Choice )
परीा राय-चौथा िवकप (Exam State परीा शहर-चौथा िवकप (Exam
ODISHA CUTTACK
4th Choice ) City 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 2022
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
Private Unaided ODISHA
/ College) Examination State)
योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY
Jagatsinghapur कू ल बोड (School Board)
Examination District) EDUCATION
का 10वीं की माकशीट/माणप के
DELHI PUB SCH IOCL TOWNSHIP PARADIP, P.O.:
अनुसार िवालय/कॉलेज का नाम कू ल / कॉलेज का पता (School /
PARADIPGARH PARADIPGARH JAGATSINGHPUR
(School/College name should be as College Address)
JAGATSINGHPUR OD ODISHA
per Class 10th Mark sheet/certificate)
रोल नंबर 10वीं माणप के अनुसार
कू ल / कॉलेज िपनकोड (School /
754141 (Roll number as per 10th 12150276
College Pincode)
certificate)
पिरणाम मोड (Result Mode) Percentage पूणा क (Total Marks) 500.0
ातांक (Obtain Marks) 484.0 ितशत (Percentage) 96.80
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 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
Private Unaided ODISHA
/ College) Examination State)
योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY
Jagatsinghapur कू ल बोड (School Board)
Examination District) EDUCATION
का 12वीं की माकशीट/माणप के
DELHI PUB SCH IOCL TOWNSHIP PARADIP, P.O.:
अनुसार िवालय/कॉलेज का नाम कू ल / कॉलेज का पता (School /
PARADIPGARH PARADIPGARH JAGATSINGHPUR
(School/College name should be as College Address)
JAGATSINGHPUR OD ODISHA
per Class 12th Mark sheet/certificate)
रोल नंबर 12वीं माणप के अनुसार
कू ल / कॉलेज िपनकोड (School /
754141 (Roll number as per 12th NA
College 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) 8249158341 ईमेल आईडी (Email ID) rkpattanaik@iffco.in
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) CPADGQRRM9
 लेन-दे न की ितिथ (Date of
परीा शु क (Exam Fee) 2000.0 01-01-1900 00:00:00 AM
Transaction)
शु क जमा िकया गया (Fee Submitted
19-11-2023 23:17:21 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 : 103.80.117.86 Date of Downloading : 19-11-2023 23:21:49 PM