सं युत वे श परीा (मु य)

Joint Entrance Examination (Main)

JEE(Main)

APPLICATION NUMBER 240310479768

DO NOT SEND THIS PAGE TO NATIONAL TESTING AGENCY (NTA).
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यितगत योरा (Contact Details) वतमान पता (Present Address)
BASANT VIHAR
पता (Premises No/ Name) ईमेल पता (Email Address) MOHITVERMA2133@GMAIL.COM
COLONY, RAIPUR
NEAR BASANT VIHAR उप-थानीयता (Sub-
थानीयता (Locality) NA
KARYALAY Locality)(Optional)
दे श कोड (Country Code) +91 दे श (Country) INDIA
राय (State) CHHATTISGARH िजला (District) Raipur
वै किपक संपक सू (Alternate
मोबाइल नंबर (Mobile Number) +91 - 9302627520 9907162900
Contact No.) (Optional)
िपन कोड (Pin Code) 492009
थायी पता (Permanent Address)
THAKKAR BAPA WARD NEAR GALAXY PUBLIC SCHOOL,
पता (Premises No/ Name) थानीयता (Locality)
NO 17 GUDHIYARI
उप-थानीयता (Sub-
NA दे श (Country) INDIA
Locality)(Optional):
राय (State) CHHATTISGARH िजला (District) Raipur
िपन कोड (Pin Code) 492009
यितगत योरा (PERSONAL DETAILS)
अयथी की जम ितिथ (Candidate's
अयथी का नाम (Candidate's Name) MOHIT KUMAR VERMA 04-06-2006
Date of Birth)
िपता / अिभभावक का नाम (Father / NARENDRA KUMAR माता / अिभभावक का नाम (Mother /
NIRMALA VERMA
Guardian Name) VERMA 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 654602185976
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 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 100001-200000
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)
B. Planning, B.Arch., परीा के स के िलए आवे दन कर
के िलए आवे दन (Apply For) Session 1 & Session 2
B.E./B.Tech (Session Of Exam Apply For)
िपता / अिभभावक यवसाय (Father / िपता / अिभभावक योयता (Father /
BUSINESS 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 City
CHHATTISGARH RAIPUR
1st Choice ) 1st Choice )
परीा राय-दूसरा िवकप (Exam State परीा शहर-दूसरा िवकप (Exam City
CHHATTISGARH BHILAI NAGAR/DURG
2nd Choice ) 2nd Choice )
परीा राय-तीसरा िवकप (Exam State परीा शहर-तीसरा िवकप (Exam City
CHHATTISGARH BILASPUR(CHHATTISGARH)
3rd Choice ) 3rd Choice )
परीा राय-चौथा िवकप (Exam State परीा शहर-चौथा िवकप (Exam City
CHHATTISGARH JAGDALPUR
4th Choice ) 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 of
उीण की िथित (Pass Status) Passed 2022
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 CHHATTISGARH
College) Examination State)
योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY
Raipur कू ल बोड (School Board)
Examination District) EDUCATION
का 10वीं की माकशीट/माणप के
अनुसार िवालय/कॉलेज का नाम कू ल / कॉलेज का पता (School /
Mohit Kumar Verma Kamal vihar dunda raipur
(School/College name should be as per College Address)
Class 10th Mark sheet/certificate)
रोल नंबर 10वीं माणप के अनुसार
कू ल / कॉलेज िपनकोड (School / College
492004 (Roll number as per 10th 12126666
Pincode)
certificate)
पिरणाम मोड (Result Mode) Percentage पूणा क (Total Marks) 500.0
ातांक (Obtain Marks) 463.0 ितशत (Percentage) 92.60
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 कू िलंग का थान (Place of
योयता परीा (Qualifying Exam) Urban
Education, New Delhi; Schooling)
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 CHHATTISGARH
College) Examination State)
योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY
Raipur कू ल बोड (School Board)
Examination District) EDUCATION
का 12वीं की माकशीट/माणप के
अनुसार िवालय/कॉलेज का नाम Krishna public school कू ल / कॉलेज का पता (School /
Kamal vihar dunda
(School/College name should be as per kamal vihar dunda raipur College Address)
Class 12th Mark sheet/certificate)
रोल नंबर 12वीं माणप के अनुसार
कू ल / कॉलेज िपनकोड (School / College
492004 (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 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) 7879112900 ईमेल आईडी (Email ID) nayanshikhaverma@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) ZIC51560174626
 लेन-दे न की ितिथ (Date of
परीा शु क (Exam Fee) 4000.0 25-11-2023 17:58:25 PM
Transaction)
शु क जमा िकया गया (Fee Submitted
25-11-2023 17:56:07 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 : 157.34.115.162 Date of Downloading : 25-11-2023 18:03:12 PM