सं युत वे श परीा (मु य)

Joint Entrance Examination (Main)

JEE(Main)
APPLICATION
240311284397
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)
GAYATRI VIHAR
पता (Premises No/ Name) ईमेल पता (Email Address) SHAILENDRASINGHBHADORIA7389@GMAIL.COM
COLONY
उप-थानीयता (Sub-
थानीयता (Locality) PINTO PARK NA
Locality)(Optional)
दे श कोड (Country Code) 91 दे श (Country) INDIA
राय (State) MADHYA PRADESH िजला (District) Gwalior
वै किपक संपक सू (Alternate
मोबाइल नंबर (Mobile Number) 91 - 9630457025 7389291140
Contact No.) (Optional)
िपन कोड (Pin Code) 474006
थायी पता (Permanent Address)
GAYATRI VIHAR
पता (Premises No/ Name) थानीयता (Locality) PINTO PARK
COLONY
उप-थानीयता (Sub-
NA दे श (Country) INDIA
Locality)(Optional):
राय (State) MADHYA PRADESH िजला (District) Gwalior
िपन कोड (Pin Code) 474006
यितगत योरा (PERSONAL DETAILS)
अयथी का नाम (Candidate's SHAILENDRA SINGH अयथी की जम ितिथ
15-09-2005
Name) BHADORIA (Candidate's Date of Birth)
िपता / अिभभावक का नाम (Father माता / अिभभावक का नाम
SPS BHADORIA MANOJ DEVI
/ Guardian Name) (Mother / Guardian Name)
िलंग (Gender) MALE राटीयता (Nationality ) INDIAN
पहचान संया (Identification
पहचान के कार (Identity Type) PAN CARD HNJPB230A
Number)
राय / केद शािसत दे श जहाँ से
12वीं / समक उीण / उपिथत
MADHYA PRADESH े णी (Category ) GENERAL
(State/ UT from where 12th/
Equivalent Passed/ Appearing)
या आपको मधुमेह ह  (Are You िनवास की जगह ( Place of
NO URBAN
Diabetic ? ) Residence )
यिद आप एक Pwd उमीदवार ह , तो
या आपके पास ब चमाक िवकलांगता
वािषक पािरवािरक आय ( Annual
है (If you are a Pwd Candidate, NA 100001-200000
Family Income )
do you have benchmark
disability)?
योयता परीा म कू ली िशा
तैयारी का तरीका ( Mode of
Self-Study का मायम ( Medium of English
Preparation )
schooling in 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 योयता
िपता / अिभभावक यवसाय (Father PUBLIC SECTOR
(Father / Guardian Matriculate
/ Guardian Occupation) SERVICE
Qualification)
माता / अिभभावक यवसाय माता / अिभभावक योयता
(Mother / Guardian Self-Employment (Mother / Guardian ILLITERATE
Occupation) Qualification)
परीा राय-पहला िवकप (Exam परीा शहर-पहला िवकप
MADHYA PRADESH GWALIOR
State 1st Choice ) (Exam City 1st Choice )
परीा राय-दूसरा िवकप (Exam परीा शहर-दूसरा िवकप (Exam
MADHYA PRADESH BHOPAL
State 2nd Choice ) City 2nd Choice )
परीा राय-तीसरा िवकप (Exam परीा शहर-तीसरा िवकप
MADHYA PRADESH SAGAR
State 3rd Choice ) (Exam 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
th
10वीं या समक योयता िववरण (10 or equivalent Qualification Details)
उीण / सिमिलत होने का वष
उीण की िथित (Pass Status) Passed 2022
(Year of Passing/Appearing)
योयता परीा (Qualifying कू िलंग का थान (Place of
10 th or equivalent Urban
Exam) Schooling)
योयता परीा राय
कू ल / कॉलेज का कार (Type of
Private Unaided (Qualifying Examination MADHYA PRADESH
School / College)
State)
योयता परीा िजला (Qualifying
Gwalior कू ल बोड (School Board) CENTRAL BOARD OF SECONDARY EDUCATION
Examination District)
का 10वीं की माकशीट/माणप के
ARMY SCHOOL
अनुसार िवालय/कॉलेज का नाम
MORAR कू ल / कॉलेज का पता (School /
(School/College name should be Near Badagaon Chaurah, mORAR CANTT GWALIOR
CANTTGWALIOR College Address)
as per Class 10th Mark
MP
sheet/certificate)
रोल नंबर 10वीं माणप के
कू ल / कॉलेज िपनकोड (School /
474006 अनुसार (Roll number as per 19134716
College Pincode)
10th certificate)
पिरणाम मोड (Result Mode) Percentage पूणा क (Total Marks) 500.0
ातांक (Obtain Marks) 395.0 ितशत (Percentage) 79.00
th
12वीं या समक योयता िववरण (12 or equivalent Qualification Details)
उीण / सिमिलत होने का वष
उीण की िथित (Pass Status) Appearing 2024
(Year of Passing/Appearing)
The final examination
of the 10+2 system,
conducted by any
recognized Central/
State Board, such as the
योयता परीा (Qualifying Central Board of कू िलंग का थान (Place of
Urban
Exam) Secondary Education, Schooling)
New Delhi; Council for
the Indian School
Certificate
Examinations, New
Delhi etc.
योयता परीा राय
कू ल / कॉलेज का कार (Type of
Private Unaided (Qualifying Examination MADHYA PRADESH
School / College)
State)
योयता परीा िजला (Qualifying
Gwalior कू ल बोड (School Board) CENTRAL BOARD OF SECONDARY EDUCATION
Examination District)
का 12वीं की माकशीट/माणप के
अनुसार िवालय/कॉलेज का नाम ARMY SCHOOL
कू ल / कॉलेज का पता (School / NEAR BADAGAON CHAURAH, MORAR CANTT
(School/College name should be MORAR CANTT
College Address) GWALIOR
as per Class 12th Mark GWALIOR MP
sheet/certificate)
रोल नंबर 12वीं माणप के
कू ल / कॉलेज िपनकोड (School /
474006 अनुसार (Roll number as per NA
College Pincode)
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 (Are you a Twin and both applying for NO
JEE (MAIN) – 2024)?
आपातकालीन संपक िववरण प (Emergency Contact Details)
दे श (Country) INDIA दे श कोड (Country Code) +91
मोबाइल नंबर (Mobile Number) 9294676724 ईमेल आईडी (Email ID) satenderbhadoriaa@gmail.com
उमीदवार ारा अपलोड की गई छिवयां (IMAGES UPLOADED BY THE CANDIDATE)
PHOTO
SIGNATURE
शु क भु गतान िववरण (Fee Payment Details)
भु गतान का कार (Payment लेन-दे न आईडी (Transaction
Online 781734
Mode) ID)
 लेन-दे न की ितिथ (Date of
परीा शु क (Exam Fee) 1000.0 29-11-2023 22:00:43 PM
Transaction)
शु क जमा िकया गया (Fee 29-11-2023 21:59:32
Submitted On) 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 : 110.227.61.51 Date of Downloading : 29-11-2023 22:01:12 PM