सं युत वे श परीा (मु य)

Joint Entrance Examination (Main)

JEE(Main)
APPLICATION
240311060768
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.
यितगत योरा (Contact Details) वतमान पता (Present Address)
पता (Premises No/ Name) VILLAGE RAIPURA ईमेल पता (Email Address) SHRAVANKUMAR.CKTD0@GMAIL.COM
उप-थानीयता (Sub-
थानीयता (Locality) TAHSIL MANIKPUR POST RAIPURA
Locality)(Optional)
दे श कोड (Country Code) 91 दे श (Country) INDIA
राय (State) UTTAR PRADESH िजला (District) Chitrakoot
वै किपक संपक सू (Alternate
मोबाइल नंबर (Mobile Number) 91 - 9532359095 7080555422
Contact No.) (Optional)
िपन कोड (Pin Code) 210205
थायी पता (Permanent Address)
पता (Premises No/ Name) VILLAGE RAIPURA थानीयता (Locality) TAHSIL MANIKPUR
उप-थानीयता (Sub-
POST RAIPURA दे श (Country) INDIA
Locality)(Optional):
राय (State) UTTAR PRADESH िजला (District) Chitrakoot
िपन कोड (Pin Code) 210205
यितगत योरा (PERSONAL DETAILS)
अयथी की जम ितिथ (Candidate's
अयथी का नाम (Candidate's Name) SURESH KUMAR 15-09-2006
Date of Birth)
िपता / अिभभावक का नाम (Father / माता / अिभभावक का नाम (Mother /
SHARDA PRASAD MUNNI DEVI
Guardian Name) 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 647780934245
Number)
PHOTOGRAPH
राय / केद शािसत दे श जहाँ से 12वीं /
समक उीण / उपिथत (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 RURAL
Diabetic ? ) Residence )
यिद आप एक Pwd उमीदवार ह , तो या
आपके पास ब चमाक िवकलांगता है (If वािषक पािरवािरक आय ( Annual
NA 0-100000
you are a Pwd Candidate, do you Family Income )
have benchmark disability)?
योयता परीा म कू ली िशा का
तैयारी का तरीका ( Mode of
Others मायम ( Medium of schooling in English
Preparation )
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 /
AGRICULTURE Illiterate
Guardian Occupation) Guardian Qualification)
माता / अिभभावक यवसाय (Mother / माता / अिभभावक योयता (Mother
Agriculture ILLITERATE
Guardian Occupation) / Guardian Qualification)
परीा राय-पहला िवकप (Exam परीा शहर-पहला िवकप (Exam
UTTAR PRADESH ALLAHABAD/PRAYAGRAJ
State 1st Choice ) City 1st Choice )
परीा राय-दूसरा िवकप (Exam परीा शहर-दूसरा िवकप (Exam
UTTAR PRADESH VARANASI
State 2nd Choice ) City 2nd Choice )
परीा राय-तीसरा िवकप (Exam परीा शहर-तीसरा िवकप (Exam
UTTAR PRADESH KANPUR
State 3rd Choice ) City 3rd Choice )
परीा राय-चौथा िवकप (Exam परीा शहर-चौथा िवकप (Exam
UTTAR PRADESH LUCKNOW
State 4th Choice ) City 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
उीण की िथित (Pass Status) Passed 2022
of Passing/Appearing)
कू िलंग का थान (Place of
योयता परीा (Qualifying Exam) 10 th or equivalent Urban
Schooling)
कू ल / कॉलेज का कार (Type of Jawahar Navodaya योयता परीा राय (Qualifying
UTTAR PRADESH
School / College) Vidyalaya (JNVs) Examination State)
योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY
Chitrakoot कू ल बोड (School Board)
Examination District) EDUCATION
का 10वीं की माकशीट/माणप के
JAWAHAR
अनुसार िवालय/कॉलेज का नाम
NAVODAYA VIDYAYA कू ल / कॉलेज का पता (School /
(School/College name should be as Manikpur chitrakoot uttar pradesh
MANIKPUR College Address)
per Class 10th Mark
CHITRAKOOT UP
sheet/certificate)
रोल नंबर 10वीं माणप के अनुसार
कू ल / कॉलेज िपनकोड (School /
74013 (Roll number as per 10th 23135465
College Pincode)
certificate)
पिरणाम मोड (Result Mode) Percentage पूणा क (Total Marks) 500.0
ातांक (Obtain Marks) 471.0 ितशत (Percentage) 94.20
th
12वीं या समक योयता िववरण (12 or equivalent Qualification Details)
उीण / सिमिलत होने का वष (Year
उीण 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
योयता परीा (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 Jawahar Navodaya योयता परीा राय (Qualifying
UTTAR PRADESH
School / College) Vidyalaya (JNVs) Examination State)
योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY
Chitrakoot कू ल बोड (School Board)
Examination District) EDUCATION
का 12वीं की माकशीट/माणप के
JAWAHAR
अनुसार िवालय/कॉलेज का नाम
NAVODAYA VIDYAYA कू ल / कॉलेज का पता (School /
(School/College name should be as Manikpur chitrakoot uttar pradesh
MANIKPUR College Address)
per Class 12th Mark
CHITRAKOOT UP
sheet/certificate)
रोल नंबर 12वीं माणप के अनुसार
कू ल / कॉलेज िपनकोड (School /
74013 (Roll number as per 12th NA
College Pincode)
certificate)
अितिरत 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) 6260656499 ईमेल आईडी (Email ID) shravandada01@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) 175205993
लेन-दे न की ितिथ (Date of
परीा शु क (Exam Fee) 900.0 NA
Transaction)
शु क जमा िकया गया (Fee Submitted
29-11-2023 18:49:29 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 : 152.58.156.126 Date of Downloading : 29-11-2023 23:59:23 PM