सं युत वे श परीा (मु य)

Joint Entrance Examination (Main)

JEE(Main)

APPLICATION NUMBER 240310520217

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) QTR NO P147/701 ईमेल पता (Email Address) 12SURYANSH@GMAIL.COM
SEKHON VIHAR , NEAR
थानीयता (Locality) DELHI CANTONMENT उप-थानीयता (Sub-Locality)(Optional)
PRAHLADPUR
दे श कोड (Country Code) 91 दे श (Country) INDIA
राय (State) DELHI िजला (District) South West Delhi
वै किपक संपक सू (Alternate Contact
मोबाइल नंबर (Mobile Number) 91 - 9458160079 7055606201
No.) (Optional)
िपन कोड (Pin Code) 110010
थायी पता (Permanent Address)
S/O COL P ROMESH
पता (Premises No/ Name) थानीयता (Locality) LAIPHAM KHUNOU
SINGH
उप-थानीयता (Sub- NEAR DON BOSCO
दे श (Country) INDIA
Locality)(Optional): SCHOOL
राय (State) MANIPUR िजला (District) Imphal East
िपन कोड (Pin Code) 795010
यितगत योरा (PERSONAL DETAILS)
PAONAM SURYANSH अयथी की जम ितिथ (Candidate's
अयथी का नाम (Candidate's Name) 16-07-2006
SINGH Date of Birth)
िपता / अिभभावक का नाम (Father / माता / अिभभावक का नाम (Mother /
COL P ROMESH SINGH LAISHRAM JENNY
Guardian Name) Guardian Name)
िलंग (Gender) MALE राटीयता (Nationality ) INDIAN
ANY OTHER VALID
पहचान के कार (Identity Type) GOVT IDENTITY WITH पहचान संया (Identification Number) 844809382080
PHOTOGRAPH
राय / केद शािसत दे श जहाँ से 12वीं /
समक उीण / उपिथत (State/ UT
DELHI े णी (Category ) GENERAL
from where 12th/ Equivalent Passed/
Appearing)
या आपको मधुमेह ह  (Are You
NO िनवास की जगह ( Place of Residence ) URBAN
Diabetic ? )
यिद आप एक Pwd उमीदवार ह , तो या
आपके पास ब चमाक िवकलांगता है (If you वािषक पािरवािरक आय ( Annual Family
NA 800000 AND ABOVE
are a Pwd Candidate, do you have Income )
benchmark disability)?
योयता परीा म कू ली िशा का मायम
तैयारी का तरीका ( Mode of Preparation
Self-Study ( Medium of schooling in qualifying English
)
exam )
परीा कद िववरण (Exam centre Details)
परीा के स के िलए आवे दन कर (Session
के िलए आवे दन (Apply For) B.E./B.Tech Session 1 & Session 2
Of Exam Apply For)
िपता / अिभभावक यवसाय (Father / DEFENCE SERVICES िपता / अिभभावक योयता (Father /
Graduate
Guardian Occupation) (ARMY , NAVY, IAF) Guardian Qualification)
माता / अिभभावक यवसाय (Mother / माता / अिभभावक योयता (Mother /
Self-Employment POST GRADUATE
Guardian Occupation) Guardian Qualification)
परीा राय-पहला िवकप (Exam State परीा शहर-पहला िवकप (Exam City 1st
DELHI DELHI/NEW DELHI
1st Choice ) Choice )
परीा राय-दूसरा िवकप (Exam State परीा शहर-दूसरा िवकप (Exam City 2nd
UTTAR PRADESH NOIDA/GREATER NOIDA
2nd Choice ) Choice )
परीा राय-तीसरा िवकप (Exam State परीा शहर-तीसरा िवकप (Exam City
HARYANA FARIDABAD
3rd Choice ) 3rd Choice )
परीा राय-चौथा िवकप (Exam State परीा शहर-चौथा िवकप (Exam City 4th
UTTAR PRADESH GHAZIABAD
4th Choice ) 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
Government Aided Private DELHI
/ College) Examination State)
योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY
South West Delhi कू ल बोड (School Board)
Examination District) EDUCATION
का 10वीं की माकशीट/माणप के
THE ARMY PUBLIC
अनुसार िवालय/कॉलेज का नाम कू ल / कॉलेज का पता (School / College RIDGE ROAD DHAULA KUAN , NEW
SCHOOL RIDGE ROAD
(School/College name should be as per Address) DELHI
DHAULA KUAN ND
Class 10th Mark sheet/certificate)
कू ल / कॉलेज िपनकोड (School / College रोल नंबर 10वीं माणप के अनुसार (Roll
110021 14277260
Pincode) number as per 10th certificate)
पिरणाम मोड (Result Mode) Percentage पूणा क (Total Marks) 500.0
ातांक (Obtain Marks) 465.0 ितशत (Percentage) 93.00
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) Appearing 2024
Passing/Appearing)
The final examination of the
10+2 system, conducted by
any recognized Central/
State Board, such as the
Central Board of Secondary
योयता परीा (Qualifying Exam) 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
Government Aided Private DELHI
/ College) Examination State)
योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY
South West Delhi कू ल बोड (School Board)
Examination District) EDUCATION
का 12वीं की माकशीट/माणप के
THE ARMY PUBLIC
अनुसार िवालय/कॉलेज का नाम कू ल / कॉलेज का पता (School / College RIDGE ROAD DHAULA KUAN, NEW
SCHOOL RIDGE ROAD
(School/College name should be as per Address) DELHI
DHAULA KUAN ND
Class 12th Mark sheet/certificate)
कू ल / कॉलेज िपनकोड (School / College रोल नंबर 12वीं माणप के अनुसार (Roll
110021 NA
Pincode) number as per 12th 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
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) 7055606202 ईमेल आईडी (Email ID) romesh34@gmail.com
उमीदवार ारा अपलोड की गई छिवयां (IMAGES UPLOADED BY THE CANDIDATE)

PHOTO

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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) 83387744848
परीा शु क (Exam Fee) 2000.0 लेन-दे न की ितिथ (Date of Transaction) 16-11-2023 19:35:11 PM
शु क जमा िकया गया (Fee Submitted
16-11-2023 19:29:53 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 : 120.57.121.147 Date of Downloading : 16-11-2023 19:35:59 PM