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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) 768B ईमेल पता (Email Address) DEEPAKKARIWAL@GMAIL.COM उप-थानीयता (Sub- थानीयता (Locality) SUMER SAGAR KARORI MAL KA HATA Locality)(Optional) दे श कोड (Country Code) 91 दे श (Country) INDIA राय (State) UTTAR PRADESH िजला (District) Gorakhpur वै किपक संपक सू (Alternate मोबाइल नंबर (Mobile Number) 91 - 9956291600 7080425500 Contact No.) (Optional) िपन कोड (Pin Code) 273001 थायी पता (Permanent Address) पता (Premises No/ Name) 768B थानीयता (Locality) SUMER SAGAR उप-थानीयता (Sub- KARORI MAL KA HATA दे श (Country) INDIA Locality)(Optional): राय (State) UTTAR PRADESH िजला (District) Gorakhpur िपन कोड (Pin Code) 273001 यितगत योरा (PERSONAL DETAILS) अयथी की जम ितिथ (Candidate's अयथी का नाम (Candidate's Name) PIYUSH KARIWAL 20-01-2006 Date of Birth) िपता / अिभभावक का नाम (Father / माता / अिभभावक का नाम (Mother / DEEPAK KARIWAL REKHA KARIWAL Guardian Name) Guardian Name) िलंग (Gender) MALE राटीयता (Nationality ) INDIAN ANY OTHER VALID पहचान संया (Identification पहचान के कार (Identity Type) GOVT IDENTITY WITH 789099229742 Number) PHOTOGRAPH राय / केद शािसत दे श जहाँ से 12वीं / समक उीण / उपिथत (State/ UT UTTAR PRADESH े 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 उमीदवार ह , तो या आपके पास ब चमाक िवकलांगता है (If you वािषक पािरवािरक आय ( Annual NA 100001-200000 are a Pwd Candidate, do you have Family Income ) benchmark disability)? योयता परीा म कू ली िशा का तैयारी का तरीका ( Mode of Preparation Self-Study मायम ( Medium of schooling in English ) 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 / िपता / अिभभावक योयता (Father / BUSINESS Matriculate Guardian Occupation) Guardian Qualification) माता / अिभभावक यवसाय (Mother / माता / अिभभावक योयता (Mother / Others GRADUATE Guardian Occupation) Guardian Qualification) परीा राय-पहला िवकप (Exam State परीा शहर-पहला िवकप (Exam City UTTAR PRADESH GORAKHPUR 1st Choice ) 1st Choice ) परीा राय-दूसरा िवकप (Exam State परीा शहर-दूसरा िवकप (Exam City UTTAR PRADESH LUCKNOW 2nd Choice ) 2nd Choice ) परीा राय-तीसरा िवकप (Exam State परीा शहर-तीसरा िवकप (Exam City UTTAR PRADESH KANPUR 3rd Choice ) 3rd Choice ) परीा राय-चौथा िवकप (Exam State परीा शहर-चौथा िवकप (Exam City UTTAR PRADESH BASTI 4th Choice ) 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 of उीण की िथित (Pass Status) Passed 2022 Passing/Appearing) योयता परीा (Qualifying Exam) 10 th or equivalent कू िलंग का थान (Place of Schooling) Urban कू ल / कॉलेज का कार (Type of School / योयता परीा राय (Qualifying Private Unaided UTTAR PRADESH College) Examination State) योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY Gorakhpur कू ल बोड (School Board) Examination District) EDUCATION का 10वीं की माकशीट/माणप के अनुसार िवालय/कॉलेज का नाम GD Goenka public school कू ल / कॉलेज का पता (School / gorakhpur (School/College name should be as per ram ngr deoria road College Address) Class 10th Mark sheet/certificate) कू ल / कॉलेज िपनकोड (School / College रोल नंबर 10वीं माणप के अनुसार 273202 23163217 Pincode) (Roll number as per 10th certificate) पिरणाम मोड (Result Mode) Percentage पूणा क (Total Marks) 600.0 ातांक (Obtain Marks) 547.0 ितशत (Percentage) 91.17 th 12वीं या समक योयता िववरण (12 or equivalent Qualification Details) उीण / सिमिलत होने का वष (Year of उीण 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 योयता परीा (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 / योयता परीा राय (Qualifying Private Unaided UTTAR PRADESH College) Examination State) योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY Gorakhpur कू ल बोड (School Board) Examination District) EDUCATION का 12वीं की माकशीट/माणप के अनुसार िवालय/कॉलेज का नाम don bosco school कू ल / कॉलेज का पता (School / gorakhpur (School/College name should be as per mahadeopuram College Address) Class 12th Mark sheet/certificate) कू ल / कॉलेज िपनकोड (School / College रोल नंबर 12वीं माणप के अनुसार 273010 NA Pincode) (Roll number as per 12th certificate) अितिरत 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) 7007017123 ईमेल आईडी (Email ID) sanskritikariwal123@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) 538614 लेन-दे न की ितिथ (Date of परीा शु क (Exam Fee) 1000.0 11-11-2023 18:34:38 PM Transaction) शु क जमा िकया गया (Fee Submitted 11-11-2023 18:33:54 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 : 223.226.153.248 Date of Downloading : 11-11-2023 18:36:16 PM