सं युत वे श परीा (मु य)

Joint Entrance Examination (Main)

JEE(Main)

APPLICATION NUMBER 240310230691

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) 30/21 ईमेल पता (Email Address) NITUJAIN937@GMAIL.COM
उप-थानीयता (Sub-
थानीयता (Locality) CHHIPITOLA NEAR RAKABGANJ POLICE STATION
Locality)(Optional)
दे श कोड (Country Code) 91 दे श (Country) INDIA
राय (State) UTTAR PRADESH िजला (District) Agra
वै किपक संपक सू (Alternate Contact
मोबाइल नंबर (Mobile Number) 91 - 9719277777 8439602013
No.) (Optional)
िपन कोड (Pin Code) 282001
थायी पता (Permanent Address)
पता (Premises No/ Name) 30/21 थानीयता (Locality) CHHIPITOLA
उप-थानीयता (Sub- NEAR RAKABGANJ
दे श (Country) INDIA
Locality)(Optional): POLICE STATION
राय (State) UTTAR PRADESH िजला (District) Agra
िपन कोड (Pin Code) 282001
यितगत योरा (PERSONAL DETAILS)
अयथी की जम ितिथ (Candidate's
अयथी का नाम (Candidate's Name) VAIBHAV JAIN 14-09-2006
Date of Birth)
िपता / अिभभावक का नाम (Father / माता / अिभभावक का नाम (Mother /
SUDEEP KUMAR JAIN NEETU JAIN
Guardian Name) Guardian Name)
िलंग (Gender) MALE राटीयता (Nationality ) INDIAN
ANY OTHER VALID
पहचान के कार (Identity Type) GOVT IDENTITY WITH पहचान संया (Identification Number) 745036267131
PHOTOGRAPH
राय / केद शािसत दे श जहाँ से 12वीं /
समक उीण / उपिथत (State/ UT
UTTAR PRADESH े णी (Category ) GENERAL
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 500001-600000
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 /
BUSINESS Others
Guardian Occupation) Guardian Qualification)
माता / अिभभावक यवसाय (Mother / माता / अिभभावक योयता (Mother /
Self-Employment OTHERS
Guardian Occupation) Guardian Qualification)
परीा राय-पहला िवकप (Exam State परीा शहर-पहला िवकप (Exam City
UTTAR PRADESH AGRA
1st Choice ) 1st Choice )
परीा राय-दूसरा िवकप (Exam State परीा शहर-दूसरा िवकप (Exam City
UTTAR PRADESH MATHURA
2nd Choice ) 2nd Choice )
परीा राय-तीसरा िवकप (Exam State परीा शहर-तीसरा िवकप (Exam City
UTTAR PRADESH GHAZIABAD
3rd Choice ) 3rd Choice )
परीा राय-चौथा िवकप (Exam State परीा शहर-चौथा िवकप (Exam City
UTTAR PRADESH ALIGARH
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 UTTAR PRADESH
College) Examination State)
योयता परीा िजला (Qualifying COUNCIL FOR THE INDIAN SCHOOL
Agra 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 / College
st peters college agra wazirpura road agra
(School/College name should be as per Address)
Class 10th Mark sheet/certificate)
कू ल / कॉलेज िपनकोड (School / College रोल नंबर 10वीं माणप के अनुसार
282003 7631805
Pincode) (Roll number as per 10th certificate)
पिरणाम मोड (Result Mode) Percentage पूणा क (Total Marks) 1000.0
ातांक (Obtain Marks) 961.0 ितशत (Percentage) 96.10
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
योयता परीा (Qualifying Exam) Board of Secondary 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 UTTAR PRADESH
College) Examination State)
योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY
Agra 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 / College
john milton public school nehru enclave shamshabad road
(School/College name should be as per Address)
Class 12th Mark sheet/certificate)
कू ल / कॉलेज िपनकोड (School / College रोल नंबर 12वीं माणप के अनुसार
282001 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) 8279404607 ईमेल आईडी (Email ID) vaibhavjain7520204002@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) CPADGPVVY7
लेन-दे न की ितिथ (Date of
परीा शु क (Exam Fee) 1000.0 01-01-1900 00:00:00 AM
Transaction)
शु क जमा िकया गया (Fee Submitted
18-11-2023 23:49:01 PM
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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 : 42.105.18.57 Date of Downloading : 18-11-2023 23:52:42 PM