सं युत वे श परीा (मु य)

Joint Entrance Examination (Main)

JEE(Main)

APPLICATION NUMBER 240311318282

DO NOT SEND THIS PAGE TO NATIONAL TESTING AGENCY (NTA).
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यितगत योरा (Contact Details) वतमान पता (Present Address)
पता (Premises No/ Name) 034 ईमेल पता (Email Address) SWAGATSAMAL935@GMAIL.COM
उप-थानीयता (Sub-
थानीयता (Locality) BIDANASI BIDANASI
Locality)(Optional)
दे श कोड (Country Code) 91 दे श (Country) INDIA
राय (State) ODISHA िजला (District) Cuttack
वै किपक संपक सू (Alternate
मोबाइल नंबर (Mobile Number) 91 - 8144245585 9337142428
Contact No.) (Optional)
िपन कोड (Pin Code) 753014
थायी पता (Permanent Address)
पता (Premises No/ Name) 034 थानीयता (Locality) BIDANASI
उप-थानीयता (Sub-
BIDANASI दे श (Country) INDIA
Locality)(Optional):
राय (State) ODISHA िजला (District) Cuttack
िपन कोड (Pin Code) 753014
यितगत योरा (PERSONAL DETAILS)
अयथी की जम ितिथ (Candidate's
अयथी का नाम (Candidate's Name) SWAGAT SAMAL 09-07-2005
Date of Birth)
िपता / अिभभावक का नाम (Father / TAPAN KUMAR माता / अिभभावक का नाम (Mother /
RASHMI REKHA SAMAL
Guardian Name) SAMAL 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 390376985094
Number)
PHOTOGRAPH
राय / केद शािसत दे श जहाँ से 12वीं /
समक उीण / उपिथत (State/ UT from
ODISHA े णी (Category ) GENERAL
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 400001-500000
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 ) Others मायम ( Medium of schooling in English
qualifying exam )
परीा कद िववरण (Exam centre Details)
परीा 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 योयता (Father /
BUSINESS Graduate
Guardian Occupation) Guardian Qualification)
माता / अिभभावक यवसाय (Mother / माता / अिभभावक योयता (Mother /
Others GRADUATE
Guardian Occupation) Guardian Qualification)
परीा राय-पहला िवकप (Exam State परीा शहर-पहला िवकप (Exam City
ODISHA CUTTACK
1st Choice ) 1st Choice )
परीा राय-दूसरा िवकप (Exam State परीा शहर-दूसरा िवकप (Exam City
ODISHA BHUBANESWAR
2nd Choice ) 2nd Choice )
परीा राय-तीसरा िवकप (Exam State परीा शहर-तीसरा िवकप (Exam City
ODISHA DHENKANAL
3rd Choice ) 3rd Choice )
परीा राय-चौथा िवकप (Exam State परीा शहर-चौथा िवकप (Exam City
ODISHA KENDRAPARA
4th Choice ) 4th Choice )
न प मायम (Question Paper Medium) English
10वीं या समक योयता िववरण (10th or equivalent Qualification Details)
उीण / सिमिलत होने का वष (Year of
उीण की िथित (Pass Status) Passed 2021
Passing/Appearing)
योयता परीा (Qualifying Exam) 10 th or equivalent कू िलंग का थान (Place of Schooling) Urban
कू ल / कॉलेज का कार (Type of School / योयता परीा राय (Qualifying
Private Unaided ODISHA
College) Examination State)
योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY
Cuttack 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 /
dav public school secc-6 , c.d.a. , cuttack
(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
753014 (Roll number as per 10th 12109477
Pincode)
certificate)
पिरणाम मोड (Result Mode) Percentage पूणा क (Total Marks) 500.0
ातांक (Obtain Marks) 383.0 ितशत (Percentage) 76.60
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) Passed 2023
Passing/Appearing)
The final examination of
the 10+2 system,
conducted by any
recognized Central/ State
Board, such as the Central
योयता परीा (Qualifying Exam) Board of Secondary 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 / योयता परीा राय (Qualifying
Private Unaided ODISHA
College) Examination State)
योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY
Cuttack कू ल बोड (School Board)
Examination District) EDUCATION
का 12वीं की माकशीट/माणप के
अनुसार िवालय/कॉलेज का नाम कू ल / कॉलेज का पता (School /
nalanda public school sec-8 , c.d.a. , tonpe road , cuttack
(School/College name should be as per College Address)
Class 12th Mark sheet/certificate)
रोल नंबर 12वीं माणप के अनुसार
कू ल / कॉलेज िपनकोड (School / College
753014 (Roll number as per 12th 12637415
Pincode)
certificate)
पिरणाम मोड (Result Mode) Percentage पूणा क (Total Marks) 500.0
ातांक (Obtain Marks) 289.0 ितशत (Percentage) 57.80
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) 8144099841 ईमेल आईडी (Email ID) ashisham014@gmail.com
उमीदवार ा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) CPADHLWEU4
लेन-दे न की ितिथ (Date of
परीा शु क (Exam Fee) 1000.0 01-01-1900 00:00:00 AM
Transaction)
शु क जमा िकया गया (Fee Submitted
30-11-2023 13:01:21 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 : 49.37.116.56 Date of Downloading : 30-11-2023 13:03:15 PM