JEE(Main) APPLICATION 240311053337 NUMBER 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) BIT MESRA MAIN GATE , BESIDE पता (Premises No/ Name) ईमेल पता (Email Address) RAJPRATAPSINGHHARSHIT@GMAIL.COM MISHRA XEROX , RUDIYA , RANCHI उप-थानीयता (Sub- थानीयता (Locality) RUDIYA NA Locality)(Optional) दे श कोड (Country Code) 91 दे श (Country) INDIA राय (State) JHARKHAND िजला (District) Ranchi वै किपक संपक सू (Alternate मोबाइल नंबर (Mobile Number) 91 - 7004839737 9470588851 Contact No.) (Optional) िपन कोड (Pin Code) 835217 थायी पता (Permanent Address) BIT MESRA MAIN GATE , BESIDE पता (Premises No/ Name) थानीयता (Locality) RUDIYA MISHRA XEROX , RUDIYA , RANCHI उप-थानीयता (Sub- NA दे श (Country) INDIA Locality)(Optional): राय (State) JHARKHAND िजला (District) Ranchi िपन कोड (Pin Code) 835217 यितगत योरा (PERSONAL DETAILS) HARSHIT RAJ PRATAP अयथी की जम ितिथ अयथी का नाम (Candidate's Name) 24-01-2005 SINGH (Candidate's Date of Birth) िपता / अिभभावक का नाम (Father / माता / अिभभावक का नाम (Mother BINOD KUMAR SINGH RAVITA DEVI Guardian Name) / Guardian Name) िलंग (Gender) MALE राटीयता (Nationality ) INDIAN ANY OTHER VALID पहचान संया (Identification पहचान के कार (Identity Type) GOVT IDENTITY WITH 860203676949 Number) PHOTOGRAPH राय / केद शािसत दे श जहाँ से 12वीं / समक उीण / उपिथत (State/ UT JHARKHAND े णी (Category ) GEN-EWS from where 12th/ Equivalent Passed/ Appearing) या आपको मधुमेह ह (Are You िनवास की जगह ( Place of NO RURAL Diabetic ? ) Residence ) यिद आप एक Pwd उमीदवार ह , तो या आपके पास ब चमाक िवकलांगता है वािषक पािरवािरक आय ( Annual NA 400001-500000 (If you are a Pwd Candidate, do Family Income ) you 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 Graduate Guardian Occupation) / Guardian Qualification) माता / अिभभावक यवसाय (Mother / माता / अिभभावक योयता (Mother Others MATRICULATE Guardian Occupation) / Guardian Qualification) परीा राय-पहला िवकप (Exam परीा शहर-पहला िवकप (Exam JHARKHAND RANCHI State 1st Choice ) City 1st Choice ) परीा राय-दूसरा िवकप (Exam परीा शहर-दूसरा िवकप (Exam JHARKHAND JAMSHEDPUR State 2nd Choice ) City 2nd Choice ) परीा राय-तीसरा िवकप (Exam परीा शहर-तीसरा िवकप (Exam JHARKHAND HAZARIBAGH State 3rd Choice ) City 3rd Choice ) परीा राय-चौथा िवकप (Exam परीा शहर-चौथा िवकप (Exam JHARKHAND BOKARO State 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 उीण की िथित (Pass Status) Passed 2021 (Year of Passing/Appearing) कू िलंग का थान (Place of योयता परीा (Qualifying Exam) 10 th or equivalent Rural Schooling) कू ल / कॉलेज का कार (Type of योयता परीा राय (Qualifying Private Unaided JHARKHAND School / College) Examination State) योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY Ranchi कू ल बोड (School Board) Examination District) EDUCATION का 10वीं की माकशीट/माणप के अनुसार िवालय/कॉलेज का नाम SURENDRANATH कू ल / कॉलेज का पता (School / (School/College name should be as Hb road , dipatoli, ranchi centenary school College Address) per Class 10th Mark sheet/certificate) रोल नंबर 10वीं माणप के अनुसार कू ल / कॉलेज िपनकोड (School / 834009 (Roll number as per 10th 22323190 College Pincode) certificate) पिरणाम मोड (Result Mode) Percentage पूणा क (Total Marks) 500.0 ातांक (Obtain Marks) 389.0 ितशत (Percentage) 77.80 th 12वीं या समक योयता िववरण (12 or equivalent Qualification Details) उीण / सिमिलत होने का वष उीण की िथित (Pass Status) Appearing 2024 (Year 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 Rural Schooling) Education, New Delhi; Council for the Indian School Certificate Examinations, New Delhi etc. कू ल / कॉलेज का कार (Type of योयता परीा राय (Qualifying Private Unaided JHARKHAND School / College) Examination State) योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY Ranchi कू ल बोड (School Board) Examination District) EDUCATION का 12वीं की माकशीट/माणप के अनुसार िवालय/कॉलेज का नाम SURENDRANATH कू ल / कॉलेज का पता (School / (School/College name should be as Hb road, dipatoli, ranchi centenary school College Address) per Class 12th Mark sheet/certificate) रोल नंबर 12वीं माणप के अनुसार कू ल / कॉलेज िपनकोड (School / 834009 (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 ह (Are you a Twin and both applying for JEE (MAIN) – NO 2024)? आपातकालीन संपक िववरण प (Emergency Contact Details) दे श (Country) INDIA दे श कोड (Country Code) +91 मोबाइल नंबर (Mobile Number) 9304929113 ईमेल आईडी (Email ID) binodbit25@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) CPADHNHGR3 लेन-दे न की ितिथ (Date of परीा शु क (Exam Fee) 900.0 01-01-1900 00:00:00 AM Transaction) शु क जमा िकया गया (Fee Submitted 30-11-2023 19:44:07 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 : 157.35.12.3 Date of Downloading : 30-11-2023 19:48:44 PM