JEE(Main) APPLICATION 240310824020 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) पता (Premises No/ Name) D-19 ईमेल पता (Email Address) AYUSHVISHWAKARMA726@GMAIL.COM KHURDHAI BAZAR, उप-थानीयता (Sub- थानीयता (Locality) MADAR MAU SULTANPUR ROAD Locality)(Optional) दे श कोड (Country Code) 91 दे श (Country) INDIA राय (State) UTTAR PRADESH िजला (District) Lucknow वै किपक संपक सू (Alternate मोबाइल नंबर (Mobile Number) 91 - 9453456810 7755005754 Contact No.) (Optional) िपन कोड (Pin Code) 226002 थायी पता (Permanent Address) पता (Premises No/ Name) D-19 थानीयता (Locality) KHURDHAI BAZAR, SULTANPUR ROAD उप-थानीयता (Sub- MADAR MAU दे श (Country) INDIA Locality)(Optional): राय (State) UTTAR PRADESH िजला (District) Lucknow िपन कोड (Pin Code) 226002 यितगत योरा (PERSONAL DETAILS) AYUSH अयथी की जम ितिथ अयथी का नाम (Candidate's Name) 07-07-2006 VISHWAKARMA (Candidate's Date of Birth) िपता / अिभभावक का नाम (Father / ARVIND KUMAR माता / अिभभावक का नाम (Mother POONAM VISHWAKARMA Guardian Name) VISHWAKARMA / Guardian Name) िलंग (Gender) MALE राटीयता (Nationality ) INDIAN ANY OTHER VALID पहचान संया (Identification पहचान के कार (Identity Type) GOVT IDENTITY 659837034267 Number) WITH PHOTOGRAPH राय / केद शािसत दे श जहाँ से 12वीं / समक उीण / उपिथत (State/ UT UTTAR PRADESH े 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 NO URBAN Diabetic ? ) Residence ) यिद आप एक Pwd उमीदवार ह , तो या आपके पास ब चमाक िवकलांगता है वािषक पािरवािरक आय ( Annual NA 500001-600000 (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 Online Coaching 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 / GOVERNMENT िपता / अिभभावक योयता (Father / Post Graduate Guardian Occupation) SERVICE 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 UTTAR PRADESH LUCKNOW State 1st Choice ) City 1st Choice ) परीा राय-दूसरा िवकप (Exam परीा शहर-दूसरा िवकप (Exam UTTAR PRADESH SULTANPUR State 2nd Choice ) City 2nd Choice ) परीा राय-तीसरा िवकप (Exam परीा शहर-तीसरा िवकप (Exam UTTAR PRADESH SITAPUR State 3rd Choice ) City 3rd Choice ) परीा राय-चौथा िवकप (Exam परीा शहर-चौथा िवकप (Exam UTTAR PRADESH FAIZABAD State 4th Choice ) City 4th Choice ) न प मायम (Question Paper Medium) English 10वीं या समक योयता िववरण (10th 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 योयता परीा राय (Qualifying Private Unaided UTTAR PRADESH School / College) Examination State) योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY Barabanki कू ल बोड (School Board) Examination District) EDUCATION का 10वीं की माकशीट/माणप के अनुसार िवालय/कॉलेज का नाम कू ल / कॉलेज का पता (School / (School/College name should be as Central Academy Awas vikas colony barabanki College Address) per Class 10th Mark sheet/certificate) रोल नंबर 10वीं माणप के अनुसार कू ल / कॉलेज िपनकोड (School / 225001 (Roll number as per 10th 23126897 College Pincode) certificate) पिरणाम मोड (Result Mode) Percentage पूणा क (Total Marks) 500.0 ातांक (Obtain Marks) 477.0 ितशत (Percentage) 95.40 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 योयता परीा राय (Qualifying Private Unaided UTTAR PRADESH School / College) Examination State) योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY Lucknow कू ल बोड (School Board) Examination District) EDUCATION का 12वीं की माकशीट/माणप के अनुसार िवालय/कॉलेज का नाम TIRUPATI Montessori कू ल / कॉलेज का पता (School / (School/College name should be as Arjunganj,SARSAWAN, lucknow school College Address) per Class 12th Mark sheet/certificate) रोल नंबर 12वीं माणप के अनुसार कू ल / कॉलेज िपनकोड (School / 226002 (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) 7985805653 ईमेल आईडी (Email ID) ayushvishwakarma639@gmail.com उमीदवार ारा अपलोड की गई छिवयां (IMAGES UPLOADED BY THE CANDIDATE)
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भु गतान का कार (Payment Mode) Online लेन-दे न आईडी (Transaction ID) CPADHEZFF0 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 27-11-2023 15:24:36 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 : 47.15.1.82 Date of Downloading : 27-11-2023 15:27:30 PM