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. यितगत योरा (Contact Details) वतमान पता (Present Address) C-6 II SHYAM PARK पता (Premises No/ Name) ईमेल पता (Email Address) 2006SHARIQUE@GMAIL.COM EXTN उप-थानीयता (Sub- थानीयता (Locality) SAHIBABAD NA Locality)(Optional) दे श कोड (Country Code) 91 दे श (Country) INDIA राय (State) UTTAR PRADESH िजला (District) Ghaziabad वै किपक संपक सू (Alternate Contact मोबाइल नंबर (Mobile Number) 91 - 8800613142 9891392513 No.) (Optional) िपन कोड (Pin Code) 201005 थायी पता (Permanent Address) C-6 II SHYAM PARK पता (Premises No/ Name) थानीयता (Locality) SAHIBABAD EXTN उप-थानीयता (Sub- NA दे श (Country) INDIA Locality)(Optional): राय (State) UTTAR PRADESH िजला (District) Ghaziabad िपन कोड (Pin Code) 201005 यितगत योरा (PERSONAL DETAILS) MD SHARIQUE अयथी की जम ितिथ (Candidate's अयथी का नाम (Candidate's Name) 01-09-2006 HUSSAIN Date of Birth) िपता / अिभभावक का नाम (Father / माता / अिभभावक का नाम (Mother / MD SHAHID HUSSAIN SHAHEEN PERWEEN Guardian Name) Guardian Name) िलंग (Gender) MALE राटीयता (Nationality ) INDIAN ANY OTHER VALID पहचान के कार (Identity Type) GOVT IDENTITY WITH पहचान संया (Identification Number) 238440817639 PHOTOGRAPH राय / केद शािसत दे श जहाँ से 12वीं / समक उीण / उपिथत (State/ UT DELHI े 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 उमीदवार ह , तो या आपके पास ब चमाक िवकलांगता है (If you वािषक पािरवािरक आय ( Annual Family NA 200001-300000 are a Pwd Candidate, do you have Income ) benchmark disability)? योयता परीा म कू ली िशा का मायम तैयारी का तरीका ( Mode of Preparation Online Coaching ( Medium of schooling in qualifying English ) 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 2 (Session Of Exam Apply For) िपता / अिभभावक यवसाय (Father / िपता / अिभभावक योयता (Father / PRIVATE SERVICE Others Guardian Occupation) Guardian Qualification) माता / अिभभावक यवसाय (Mother / माता / अिभभावक योयता (Mother / Others MATRICULATE Guardian Occupation) Guardian Qualification) परीा राय-पहला िवकप (Exam State परीा शहर-पहला िवकप (Exam City UTTAR PRADESH GHAZIABAD 1st Choice ) 1st Choice ) परीा राय-दूसरा िवकप (Exam State परीा शहर-दूसरा िवकप (Exam City UTTAR PRADESH NOIDA/GREATER NOIDA 2nd Choice ) 2nd Choice ) परीा राय-तीसरा िवकप (Exam State परीा शहर-तीसरा िवकप (Exam City UTTAR PRADESH MEERUT 3rd Choice ) 3rd Choice ) परीा राय-चौथा िवकप (Exam State परीा शहर-चौथा िवकप (Exam City UTTAR PRADESH ALIGARH 4th Choice ) 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 of उीण की िथित (Pass Status) Passed 2022 Passing/Appearing) योयता परीा (Qualifying Exam) 10 th or equivalent कू िलंग का थान (Place of Schooling) Urban कू ल / कॉलेज का कार (Type of School / योयता परीा राय (Qualifying Private Unaided UTTAR PRADESH College) Examination State) योयता परीा िजला (Qualifying COUNCIL FOR THE INDIAN SCHOOL Ghaziabad कू ल बोड (School Board) Examination District) CERTIFICATE EXAMINATIONS का 10वीं की माकशीट/माणप के अनुसार िवालय/कॉलेज का नाम कू ल / कॉलेज का पता (School / College HOLY angels school sector-3 rajender nagar,sahibabad (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 (Roll 201005 7700889 Pincode) number as per 10th certificate) पिरणाम मोड (Result Mode) Percentage पूणा क (Total Marks) 1000.0 ातांक (Obtain Marks) 715.0 ितशत (Percentage) 71.50 th 12वीं या समक योयता िववरण (12 or equivalent Qualification Details) उीण / सिमिलत होने का वष (Year of उीण 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 योयता परीा (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 / योयता परीा राय (Qualifying Private Unaided DELHI College) Examination State) योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY East Delhi कू ल बोड (School Board) Examination District) EDUCATION का 12वीं की माकशीट/माणप के अनुसार िवालय/कॉलेज का नाम queen global international कू ल / कॉलेज का पता (School / College c-block,main road,dilshad (School/College name should be as per school Address) garden,delhi-110095 Class 12th Mark sheet/certificate) कू ल / कॉलेज िपनकोड (School / College रोल नंबर 12वीं माणप के अनुसार (Roll 110095 NA Pincode) number as per 12th certificate) अितिरत 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) 7827002375 ईमेल आईडी (Email ID) 2175shahid@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) ZIC51526626688 परीा शु क (Exam Fee) 1800.0 लेन-दे न की ितिथ (Date of Transaction) 10-11-2023 21:29:15 PM शु क जमा िकया गया (Fee Submitted 10-11-2023 21:28:36 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 : 103.67.18.124 Date of Downloading : 10-11-2023 21:30:23 PM