सं युत वे श परीा (मु य)

Joint Entrance Examination (Main)

JEE(Main)

APPLICATION NUMBER 240311113416

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) H.NO 16-2-867/9 ईमेल पता (Email Address) FAUZANASIF423@GMAIL.COM
उप-थानीयता (Sub-
थानीयता (Locality) MALAKPET AKBAR BAGH
Locality)(Optional)
दे श कोड (Country Code) 91 दे श (Country) INDIA
राय (State) TELANGANA िजला (District) Hyderabad
वै किपक संपक सू (Alternate
मोबाइल नंबर (Mobile Number) 91 - 9966960075 8341960075
Contact No.) (Optional)
िपन कोड (Pin Code) 500036
थायी पता (Permanent Address)
पता (Premises No/ Name) H.NO 16-2-867/9 थानीयता (Locality) MALAKPET
उप-थानीयता (Sub-
AKBAR BAGH दे श (Country) INDIA
Locality)(Optional):
राय (State) TELANGANA िजला (District) Hyderabad
िपन कोड (Pin Code) 500036
यितगत योरा (PERSONAL DETAILS)
MUHAMMAD FAUZAN अयथी की जम ितिथ (Candidate's
अयथी का नाम (Candidate's Name) 04-04-2006
ASIF Date of Birth)
िपता / अिभभावक का नाम (Father / माता / अिभभावक का नाम (Mother /
MOHAMMED ASIF SOUBIA RAFATH
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 732244538692
Number)
PHOTOGRAPH
राय / केद शािसत दे श जहाँ से 12वीं /
समक उीण / उपिथत (State/ UT
TELANGANA े 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 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
Tutorial Classes in School 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 /
SELF-EMPLOYMENT Graduate
Guardian Occupation) Guardian Qualification)
माता / अिभभावक यवसाय (Mother / माता / अिभभावक योयता (Mother /
Others GRADUATE
Guardian Occupation) Guardian Qualification)
परीा राय-पहला िवकप (Exam State परीा शहर-पहला िवकप (Exam City
TELANGANA HYDERABAD/SECUNDERABAD
1st Choice ) 1st Choice )
परीा राय-दूसरा िवकप (Exam State परीा शहर-दूसरा िवकप (Exam City
TELANGANA NALGONDA
2nd Choice ) 2nd Choice )
परीा राय-तीसरा िवकप (Exam परीा शहर-तीसरा िवकप (Exam City
TELANGANA SURYAPET
State 3rd Choice ) 3rd Choice )
परीा राय-चौथा िवकप (Exam State परीा शहर-चौथा िवकप (Exam City
TELANGANA WARANGAL
4th Choice ) 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 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
Private Unaided TELANGANA
/ College) Examination State)
योयता परीा िजला (Qualifying TELANGANA BOARD OF
Hyderabad कू ल बोड (School Board)
Examination District) SECONDARY EDUCATION
का 10वीं की माकशीट/माणप के
अनुसार िवालय/कॉलेज का नाम
कू ल / कॉलेज का पता (School / Chirag Ali Ln, Abids, Hyderabad,
(School/College name should be as little flower high school
College Address) Telangana 500001
per Class 10th Mark
sheet/certificate)
रोल नंबर 10वीं माणप के अनुसार
कू ल / कॉलेज िपनकोड (School /
500001 (Roll number as per 10th 2222141852
College Pincode)
certificate)
अिधकतम ग े ड वाइंट (Max Grade
पिरणाम मोड (Result Mode) CGPA 10.0
Point)
सीजीपीए ात िकया (Obtained संचयी ितशत (Cumulative
8.8000000000000007 8.8
CGPA) Percentage)
12वीं या समक योयता िववरण (12th or equivalent Qualification Details)
उीण / सिमिलत होने का वष (Year of
उीण की िथित (Pass Status) Appearing 2024
Passing/Appearing)
Intermediate or two-year Pre-
University examination
योयता परीा (Qualifying Exam) कू िलंग का थान (Place of Schooling) Urban
conducted by a recognized
Board/ University.
कू ल / कॉलेज का कार (Type of School योयता परीा राय (Qualifying
Private Unaided TELANGANA
/ College) Examination State)
योयता परीा िजला (Qualifying TELANGANA STATE BOARD OF
Hyderabad कू ल बोड (School Board)
Examination District) INTERMEDIATE EDUCATION
का 12वीं की माकशीट/माणप के
अनुसार िवालय/कॉलेज का नाम Main Campus 3-5-947&948,
कू ल / कॉलेज का पता (School /
(School/College name should be as Sri Chaitanya Junior Kalasala Narayanguda Main Rd, Narayanguda,
College Address)
per Class 12th Mark Hyderabad, Telangana 500029
sheet/certificate)
रोल नंबर 12वीं माणप के अनुसार
कू ल / कॉलेज िपनकोड (School /
500029 (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) 9121795950 ईमेल आईडी (Email ID) soubia763@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) 84069058475
लेन-दे न की ितिथ (Date of
परीा शु क (Exam Fee) 1000.0 27-11-2023 17:43:00 PM
Transaction)
शु क जमा िकया गया (Fee Submitted
27-11-2023 17:40:13 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 : 182.18.191.138 Date of Downloading : 27-11-2023 17:45:10 PM