सं युत वे श परीा (मु य)

Joint Entrance Examination (Main)

JEE(Main)

APPLICATION NUMBER 240311340219

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)
DR HARI SINGH GOUR
पता (Premises No/ Name) ईमेल पता (Email Address) RY3621243@GMAIL.COM
UNIVERSITY
थानीयता (Locality) SAGAR उप-थानीयता (Sub-Locality)(Optional) NA
दे श कोड (Country Code) 91 दे श (Country) INDIA
राय (State) MADHYA PRADESH िजला (District) Sagar
वै किपक संपक सू (Alternate Contact
मोबाइल नंबर (Mobile Number) 91 - 9301784370 7770802221
No.) (Optional)
िपन कोड (Pin Code) 470001
थायी पता (Permanent Address)
DR HARI SINGH GOUR
पता (Premises No/ Name) थानीयता (Locality) SAGAR
UNIVERSITY
उप-थानीयता (Sub-
NA दे श (Country) INDIA
Locality)(Optional):
राय (State) MADHYA PRADESH िजला (District) Sagar
िपन कोड (Pin Code) 470001
यितगत योरा (PERSONAL DETAILS)
अयथी की जम ितिथ (Candidate's Date
अयथी का नाम (Candidate's Name) RITESH YADAV 28-02-2006
of Birth)
िपता / अिभभावक का नाम (Father / माता / अिभभावक का नाम (Mother /
HARLAL YADAV KRANEI YADAV
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) 477162305282
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
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 0-100000
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 / िपता / अिभभावक योयता (Father /
AGRICULTURE Matriculate
Guardian Occupation) Guardian Qualification)
माता / अिभभावक यवसाय (Mother / माता / अिभभावक योयता (Mother /
Others MATRICULATE
Guardian Occupation) Guardian Qualification)
परीा राय-पहला िवकप (Exam State परीा शहर-पहला िवकप (Exam City 1st
MADHYA PRADESH SAGAR
1st Choice ) Choice )
परीा राय-दूसरा िवकप (Exam State परीा शहर-दूसरा िवकप (Exam City 2nd
MADHYA PRADESH BHOPAL
2nd Choice ) Choice )
परीा राय-तीसरा िवकप (Exam State परीा शहर-तीसरा िवकप (Exam City 3rd
MADHYA PRADESH INDORE
3rd Choice ) Choice )
परीा राय-चौथा िवकप (Exam State परीा शहर-चौथा िवकप (Exam City 4th
MADHYA PRADESH JABALPUR
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 2022
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 MADHYA PRADESH
College) Examination State)
योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY
Sagar कू ल बोड (School Board)
Examination District) EDUCATION
का 10वीं की माकशीट/माणप के
अनुसार िवालय/कॉलेज का नाम कू ल / कॉलेज का पता (School / College Pili Kothi, 38, Civil Line, Sagar Cantt.,
Vatsalya public School
(School/College name should be as per Address) Sagar, Madhya Pradesh 470001
Class 10th Mark sheet/certificate)
कू ल / कॉलेज िपनकोड (School / College रोल नंबर 10वीं माणप के अनुसार (Roll
470001 19183057
Pincode) number as per 10th certificate)
पिरणाम मोड (Result Mode) Percentage पूणा क (Total Marks) 500.0
ातांक (Obtain Marks) 426.0 ितशत (Percentage) 85.20
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)
Candidates who have
completed the Class 12 (or
equivalent) examination
outside India or from a
Board not specified above
should produce a certificate
योयता परीा (Qualifying Exam) कू िलंग का थान (Place of Schooling) Urban
from the Association of
Indian Universities (AIU)
to the effect that the
examination they have
passed is equivalent to the
Class 12 Examination
कू ल / कॉलेज का कार (Type of School / योयता परीा राय (Qualifying
Private Unaided MADHYA PRADESH
College) Examination State)
योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY
Sagar कू ल बोड (School Board)
Examination District) EDUCATION
का 12वीं की माकशीट/माणप के
अनुसार िवालय/कॉलेज का नाम कू ल / कॉलेज का पता (School / College Pili Kothi, 38, Civil Line, Sagar Cantt.,
vatasalya public school
(School/College name should be as per Address) Sagar, Madhya Pradesh 470001
Class 12th Mark sheet/certificate)
कू ल / कॉलेज िपनकोड (School / College रोल नंबर 12वीं माणप के अनुसार (Roll
470001 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) 7000020415 ईमेल आईडी (Email ID) rohitasjay903203@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)
परीा शु क (Exam Fee)
शु क जमा िकया गया (Fee Submitted
On)
Online लेन-दे न आईडी (Transaction ID) CPADHMUCS1
1800.0 लेन-दे न की ितिथ (Date of Transaction) 01-01-1900 00:00:00 AM
30-11-2023 17:12:03 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 : 157.34.74.116 Date of Downloading : 07-12-2023 10:42:36 AM