सं युत वे श परीा (मु य)

Joint Entrance Examination (Main)

JEE(Main)
APPLICATION
240310012288
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) WAIDHAN (EAST) ईमेल पता (Email Address) SHAHSHIVAM1234512@GMAIL.COM
उप-थानीयता (Sub-
थानीयता (Locality) GHURITAL GHURITAL EAST
Locality)(Optional)
दे श कोड (Country Code) 91 दे श (Country) INDIA
राय (State) MADHYA PRADESH िजला (District) Singrauli
वै किपक संपक सू (Alternate
मोबाइल नंबर (Mobile Number) 91 - 8357951692 8871510897
Contact No.) (Optional)
िपन कोड (Pin Code) 486886
थायी पता (Permanent Address)
पता (Premises No/ Name) WAIDHAN (EAST) थानीयता (Locality) GHURITAL
उप-थानीयता (Sub-
GHURITAL EAST दे श (Country) INDIA
Locality)(Optional):
राय (State) MADHYA PRADESH िजला (District) Singrauli
िपन कोड (Pin Code) 486886
यितगत योरा (PERSONAL DETAILS)
अयथी की जम ितिथ
अयथी का नाम (Candidate's Name) SHIVAM SHAH 07-07-2005
(Candidate's Date of Birth)
िपता / अिभभावक का नाम (Father / माता / अिभभावक का नाम (Mother
VIJAY NARAYAN SHAH SUNITA SHAH
Guardian Name) / Guardian Name)
िलंग (Gender) MALE राटीयता (Nationality ) INDIAN
ANY OTHER VALID GOVT
पहचान संया (Identification
पहचान के कार (Identity Type) IDENTITY WITH 406232702543
Number)
PHOTOGRAPH
राय / केद शािसत दे श जहाँ से 12वीं
/ समक उीण / उपिथत (State/ UT
MADHYA 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 वािषक पािरवािरक आय ( Annual
NA 0-100000
(If you are a Pwd Candidate, do Family Income )
you have benchmark disability)?
योयता परीा म कू ली िशा का
तैयारी का तरीका ( Mode of
Online Coaching 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 2
(Session Of Exam Apply For)
िपता / अिभभावक यवसाय (Father / िपता / अिभभावक योयता (Father /
AGRICULTURE Others
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
MADHYA PRADESH SATNA
State 1st Choice ) City 1st Choice )
परीा राय-दूसरा िवकप (Exam परीा शहर-दूसरा िवकप (Exam
MADHYA PRADESH JABALPUR
State 2nd Choice ) City 2nd Choice )
परीा राय-तीसरा िवकप (Exam परीा शहर-तीसरा िवकप (Exam
MADHYA PRADESH BHOPAL
State 3rd Choice ) City 3rd Choice )
परीा राय-चौथा िवकप (Exam परीा शहर-चौथा िवकप (Exam
MADHYA PRADESH INDORE
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 Rural
Schooling)
कू ल / कॉलेज का कार (Type of योयता परीा राय (Qualifying
Private Unaided MADHYA PRADESH
School / College) Examination State)
योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY
Singrauli कू ल बोड (School Board)
Examination District) EDUCATION
का 10वीं की माकशीट/माणप के
अनुसार िवालय/कॉलेज का नाम
DAV PUBLIC SCHOOL, कू ल / कॉलेज का पता (School / DUDHICHUA,JAYANt DiSTRICT-
(School/College name should be as
DUDHICHUA College Address) SINGRAULI(MP)
per Class 10th Mark
sheet/certificate)
रोल नंबर 10वीं माणप के अनुसार
कू ल / कॉलेज िपनकोड (School /
486888 (Roll number as per 10th 19195901
College Pincode)
certificate)
पिरणाम मोड (Result Mode) Percentage पूणा क (Total Marks) 500.0
ातांक (Obtain Marks) 455.0 ितशत (Percentage) 91.00
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) Rural
Board of Secondary Education, Schooling)
New Delhi; Council for the
Indian School Certificate
Examinations, New Delhi etc.
कू ल / कॉलेज का कार (Type of योयता परीा राय (Qualifying
Private Unaided MADHYA PRADESH
School / College) Examination State)
योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY
Singrauli कू ल बोड (School Board)
Examination District) EDUCATION
का 12वीं की माकशीट/माणप के
अनुसार िवालय/कॉलेज का नाम
DAV PUBLIC कू ल / कॉलेज का पता (School / DUDHICHUA,JAYANT DISTRICT-
(School/College name should be as
SCHOOL,DUDHICHUA College Address) SINGRAULI (MP)
per Class 12th Mark
sheet/certificate)
रोल नंबर 12वीं माणप के अनुसार
कू ल / कॉलेज िपनकोड (School /
486888 (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
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) 9575993734 ईमेल आईडी (Email ID) jprohit85@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) CPADGSWFU8
लेन-दे न की ितिथ (Date of
परीा शु क (Exam Fee) 1800.0 01-01-1900 00:00:00 AM
Transaction)
शु क जमा िकया गया (Fee Submitted
21-11-2023 10:01:42 AM
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 : 1.187.216.39 Date of Downloading : 21-11-2023 10:11:03 AM