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THE CANDIDATE IS REQUESTED TO RETAIN THE PRINTOUT OF THE CONFIRMATION PAGE FOR FUTURE REFERENCE. यितगत योरा (Contact Details) वतमान पता (Present Address) H NO B-1/3630/3 पता (Premises No/ Name) ईमेल पता (Email Address) PRACHICHAUHAN3630@GMAIL.COM RAJPURA उप-थानीयता (Sub- थानीयता (Locality) MOHINDER GANJ NA Locality)(Optional) दे श कोड (Country Code) 91 दे श (Country) INDIA राय (State) PUNJAB िजला (District) Patiala वै किपक संपक सू (Alternate मोबाइल नंबर (Mobile Number) 91 - 9888421052 NA Contact No.) (Optional) िपन कोड (Pin Code) 140401 थायी पता (Permanent Address) H NO B-1/3630/3 पता (Premises No/ Name) थानीयता (Locality) MOHINDER GANJ RAJPURA उप-थानीयता (Sub- NA दे श (Country) INDIA Locality)(Optional): राय (State) PUNJAB िजला (District) Patiala िपन कोड (Pin Code) 140401 यितगत योरा (PERSONAL DETAILS) अयथी की जम ितिथ (Candidate's अयथी का नाम (Candidate's Name) PRACHI 24-09-2006 Date of Birth) िपता / अिभभावक का नाम (Father / माता / अिभभावक का नाम (Mother / GOPAL CHAND SONIA RANI Guardian Name) Guardian Name) िलंग (Gender) FEMALE राटीयता (Nationality ) INDIAN ANY OTHER VALID पहचान संया (Identification पहचान के कार (Identity Type) GOVT IDENTITY WITH 234970609617 Number) PHOTOGRAPH राय / केद शािसत दे श जहाँ से 12वीं / समक उीण / उपिथत (State/ UT PUNJAB े 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 उमीदवार ह , तो या आपके पास ब चमाक िवकलांगता है (If वािषक पािरवािरक आय ( Annual NA 100001-200000 you are a Pwd Candidate, do you Family Income ) have benchmark disability)? योयता परीा म कू ली िशा का तैयारी का तरीका ( Mode of Self-Study मायम ( Medium of schooling in English Preparation ) qualifying exam ) परीा कद िववरण (Exam centre Details) परीा 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 योयता (Father / PRIVATE SERVICE Matriculate Guardian Occupation) Guardian Qualification) माता / अिभभावक यवसाय (Mother / माता / अिभभावक योयता (Mother / Private Service GRADUATE Guardian Occupation) Guardian Qualification) परीा राय-पहला िवकप (Exam State परीा शहर-पहला िवकप (Exam PUNJAB PATIALA/FATEHGARH SAHIB 1st Choice ) City 1st Choice ) परीा राय-दूसरा िवकप (Exam State परीा शहर-दूसरा िवकप (Exam PUNJAB SAHIBZADA AJIT SINGH NAGAR 2nd Choice ) City 2nd Choice ) परीा राय-तीसरा िवकप (Exam परीा शहर-तीसरा िवकप (Exam HARYANA AMBALA State 3rd Choice ) City 3rd Choice ) परीा राय-चौथा िवकप (Exam State परीा शहर-चौथा िवकप (Exam PUNJAB LUDHIANA 4th Choice ) City 4th Choice ) न प मायम (Question Paper Medium) English th 10वीं या समक योयता िववरण (10 or equivalent Qualification Details) उीण / सिमिलत होने का वष (Year उीण की िथित (Pass Status) Passed 2022 of Passing/Appearing) कू िलंग का थान (Place of योयता परीा (Qualifying Exam) 10 th or equivalent Urban Schooling) कू ल / कॉलेज का कार (Type of School योयता परीा राय (Qualifying Private Unaided PUNJAB / College) Examination State) योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY Patiala कू ल बोड (School Board) Examination District) EDUCATION का 10वीं की माकशीट/माणप के अनुसार िवालय/कॉलेज का नाम ADHARSHILA THE कू ल / कॉलेज का पता (School / (School/College name should be as FOUNDATION INTL RAJPURa patiala road College Address) per Class 10th Mark SCHOOL sheet/certificate) रोल नंबर 10वीं माणप के अनुसार कू ल / कॉलेज िपनकोड (School / 140401 (Roll number as per 10th 13221540 College Pincode) certificate) पिरणाम मोड (Result Mode) Percentage पूणा क (Total Marks) 500.0 ातांक (Obtain Marks) 368.0 ितशत (Percentage) 73.60 th 12वीं या समक योयता िववरण (12 or equivalent Qualification Details) उीण / सिमिलत होने का वष (Year उीण 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 योयता परीा (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 योयता परीा राय (Qualifying Private Unaided PUNJAB / College) Examination State) योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY Patiala कू ल बोड (School Board) Examination District) EDUCATION का 12वीं की माकशीट/माणप के अनुसार िवालय/कॉलेज का नाम ADHARSHILA THE कू ल / कॉलेज का पता (School / (School/College name should be as FOUNDATION INTL RAJPURA PATIALA ROAD College Address) per Class 12th Mark SCHOOL sheet/certificate) रोल नंबर 12वीं माणप के अनुसार कू ल / कॉलेज िपनकोड (School / 140401 (Roll number as per 12th NA College Pincode) certificate) अितिरत 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) 7696176812 ईमेल आईडी (Email ID) soniachauhanmintu@gmail.com उमीदवार ा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) ZIC51569189823 लेन-दे न की ितिथ (Date of परीा शु क (Exam Fee) 800.0 29-11-2023 19:58:57 PM Transaction) शु क जमा िकया गया (Fee Submitted 29-11-2023 19:58:17 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 : 49.36.184.210 Date of Downloading : 29-11-2023 19:59:16 PM