सं युत वे श परीा (मु य)

Joint Entrance Examination (Main)

JEE(Main)
APPLICATION
240310035450
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) BHAGAPUR ईमेल पता (Email Address) PRABHUDATTAPANDA2005@GMAIL.COM
उप-थानीयता (Sub-
थानीयता (Locality) BETADA ARUHA
Locality)(Optional)
दे श कोड (Country Code) 91 दे श (Country) INDIA
राय (State) ODISHA िजला (District) Bhadrak
वै किपक संपक सू (Alternate
मोबाइल नंबर (Mobile Number) 91 - 8260318553 9178883556
Contact No.) (Optional)
िपन कोड (Pin Code) 756168
थायी पता (Permanent Address)
पता (Premises No/ Name) BHAGAPUR थानीयता (Locality) BETADA
उप-थानीयता (Sub-
ARUHA दे श (Country) INDIA
Locality)(Optional):
राय (State) ODISHA िजला (District) Bhadrak
िपन कोड (Pin Code) 756168
यितगत योरा (PERSONAL DETAILS)
PRABHUDATTA अयथी की जम ितिथ (Candidate's
अयथी का नाम (Candidate's Name) 17-04-2005
PANDA Date of Birth)
िपता / अिभभावक का नाम (Father / SAILENDRA माता / अिभभावक का नाम (Mother
NARMADA PANDA
Guardian Name) NARAYAN PANDA / Guardian Name)
िलंग (Gender) MALE राटीयता (Nationality ) INDIAN
पहचान संया (Identification
पहचान के कार (Identity Type) PAN CARD HOPPP0974C
Number)
राय / केद शािसत दे श जहाँ से 12वीं
/ समक उीण / उपिथत (State/ UT
ODISHA े णी (Category ) GENERAL
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 100001-200000
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
Self-Study 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 / TEACHING / िपता / अिभभावक योयता (Father /
Graduate
Guardian Occupation) RESEARCH Guardian Qualification)
माता / अिभभावक यवसाय (Mother / माता / अिभभावक योयता (Mother
Others GRADUATE
Guardian Occupation) / Guardian Qualification)
परीा राय-पहला िवकप (Exam परीा शहर-पहला िवकप (Exam
ODISHA BHUBANESWAR
State 1st Choice ) City 1st Choice )
परीा राय-दूसरा िवकप (Exam परीा शहर-दूसरा िवकप (Exam
ODISHA BHADRAK
State 2nd Choice ) City 2nd Choice )
परीा राय-तीसरा िवकप (Exam परीा शहर-तीसरा िवकप (Exam
ODISHA CUTTACK
State 3rd Choice ) City 3rd Choice )
परीा राय-चौथा िवकप (Exam परीा शहर-चौथा िवकप (Exam
ODISHA BALASORE (BALESWAR)
State 4th Choice ) City 4th Choice )
न प मायम (Question Paper Medium) English
th
10वीं या समक योयता िववरण (10 or equivalent Qualification Details)
 उीण / सिमिलत होने का वष (Year
उीण की िथित (Pass Status) Passed 2021
of Passing/Appearing)
कू िलंग का थान (Place of
योयता परीा (Qualifying Exam) 10 th or equivalent Rural
Schooling)
कू ल / कॉलेज का कार (Type of योयता परीा राय (Qualifying
Government School ODISHA
School / College) Examination State)
योयता परीा िजला (Qualifying
Bhadrak कू ल बोड (School Board) ODISHA BOARD OF SECONDARY EDUCATION
Examination District)
का 10वीं की माकशीट/माणप के
अनुसार िवालय/कॉलेज का नाम
ARuha grampanchayat कू ल / कॉलेज का पता (School /
(School/College name should be as bhagapur
high school College Address)
per Class 10th Mark
sheet/certificate)
रोल नंबर 10वीं माणप के अनुसार
कू ल / कॉलेज िपनकोड (School /
756168 (Roll number as per 10th 133cb0192
College Pincode)
certificate)
पिरणाम मोड (Result Mode) Percentage पूणा क (Total Marks) 600.0
ातांक (Obtain Marks) 561.0 ितशत (Percentage) 93.50
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) Passed 2023
of Passing/Appearing)
Intermediate or two-year
Pre-University
कू िलंग का थान (Place of
योयता परीा (Qualifying Exam) examination conducted Urban
Schooling)
by a recognized Board/
University.
कू ल / कॉलेज का कार (Type of योयता परीा राय (Qualifying
Government School ODISHA
School / College) Examination State)
योयता परीा िजला (Qualifying ODISHA COUNCIL OF HIGHER SECONDARY
Baleshwar कू ल बोड (School Board)
Examination District) EDUCATION
का 12वीं की माकशीट/माणप के
अनुसार िवालय/कॉलेज का नाम
upendra nath higher कू ल / कॉलेज का पता (School /
(School/College name should be as soro
secondary school College Address)
per Class 12th Mark
sheet/certificate)
रोल नंबर 12वीं माणप के अनुसार
कू ल / कॉलेज िपनकोड (School /
756045 (Roll number as per 12th 345aa029
College Pincode)
certificate)
पिरणाम मोड (Result Mode) Percentage पूणा क (Total Marks) 600.0
ातांक (Obtain Marks) 433.0 ितशत (Percentage) 72.17
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) 8327742809 ईमेल आईडी (Email ID) prabhudattapanda77@gmail.com
उमीदवार ारा अपलोड की गई छिवयां (IMAGES UPLOADED BY THE CANDIDATE)

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शु क भु गतान िववरण (Fee Payment Details)

भु गतान का कार (Payment Mode) Online लेन-दे न आईडी (Transaction ID) CPADFQTJH6
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 04-11-2023 17:14:13
On) PM
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 : 152.58.149.224 Date of Downloading : 04-11-2023 17:17:32 PM