सं युत वे श परीा (मु य)

Joint Entrance Examination (Main)

JEE(Main)
APPLICATION
240311208807
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)
32,GALI NO-6,VEDRAM COLONY,PALLA
पता (Premises No/ Name) ईमेल पता (Email Address) RAJRAJPI41@GMAIL.COM
NO-1,AMARNAGAR,FARIDABAD,HARYANA,121003
उप-थानीयता (Sub-
थानीयता (Locality) VEDRAM COLONY NA
Locality)(Optional)
दे श कोड (Country Code) +91 दे श (Country) INDIA
राय (State) HARYANA िजला (District) Faridabad
वै किपक संपक सू
मोबाइल नंबर (Mobile
+91 - 8802968601 (Alternate Contact 9891393605
Number)
No.) (Optional)
िपन कोड (Pin Code) 121003
थायी पता (Permanent Address)
32,GALI NO-6,VEDRAM COLONY,PALLA
पता (Premises No/ Name) थानीयता (Locality) VEDRAM COLONY
NO-1,AMARNAGAR,FARIDABAD,HARYANA,121003
उप-थानीयता (Sub-
NA दे श (Country) INDIA
Locality)(Optional):
राय (State) HARYANA िजला (District) Faridabad
िपन कोड (Pin Code) 121003
यितगत योरा (PERSONAL DETAILS)
अयथी की जम ितिथ
अयथी का नाम
RAJ SINGH (Candidate's Date of 01-01-2007
(Candidate's Name)
Birth)
िपता / अिभभावक का नाम माता / अिभभावक का नाम
(Father / Guardian BADAN SINGH (Mother / Guardian VEDWATI DEVI
Name) Name)
िलंग (Gender) MALE राटीयता (Nationality ) INDIAN
पहचान के कार (Identity ANY OTHER VALID GOVT IDENTITY WITH पहचान संया
395742872740
Type) PHOTOGRAPH (Identification Number)
राय / केद शािसत दे श
जहाँ से 12वीं / समक
उीण / उपिथत (State/
HARYANA े णी (Category ) GENERAL
UT from where 12th/
Equivalent Passed/
Appearing)
या आपको मधुमेह ह  िनवास की जगह ( Place of
NO RURAL
(Are You Diabetic ? ) Residence )
यिद आप एक Pwd
उमीदवार ह , तो या आपके
पास ब चमाक िवकलांगता है वािषक पािरवािरक आय (
NA 400001-500000
(If you are a Pwd Annual Family Income )
Candidate, do you have
benchmark disability)?
योयता परीा म कू ली
तैयारी का तरीका ( Mode of िशा का मायम ( Medium
Self-Study English
Preparation ) of schooling in qualifying
exam )
परीा कद िववरण (Exam centre Details)
परीा के स के िलए आवे दन
के िलए आवे दन (Apply
B.E./B.Tech कर (Session Of Exam Session 1 & Session 2
For)
Apply For)
िपता / अिभभावक यवसाय िपता / अिभभावक योयता
(Father / Guardian SELF-EMPLOYMENT (Father / Guardian Matriculate
Occupation) Qualification)
माता / अिभभावक यवसाय माता / अिभभावक योयता
(Mother / Guardian Others (Mother / Guardian ILLITERATE
Occupation) Qualification)
परीा राय-पहला िवकप परीा शहर-पहला िवकप
HARYANA FARIDABAD
(Exam State 1st Choice ) (Exam City 1st Choice )
परीा राय-दूसरा िवकप परीा शहर-दूसरा िवकप
DELHI DELHI/NEW DELHI
(Exam State 2nd Choice ) (Exam City 2nd Choice )
परीा राय-तीसरा िवकप परीा शहर-तीसरा िवकप
UTTAR PRADESH AGRA
(Exam State 3rd Choice ) (Exam City 3rd Choice )
परीा राय-चौथा िवकप परीा शहर-चौथा िवकप
PUNJAB AMRITSAR
(Exam State 4th Choice ) (Exam 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
उीण की िथित (Pass
Passed वष (Year of 2022
Status)
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
Private Unaided (Qualifying Examination HARYANA
(Type of School / College)
State)
योयता परीा िजला
HARYANA BOARD OF SCHOOL
(Qualifying Examination Faridabad कू ल बोड (School Board)
EDUCATION
District)
का 10वीं की
माकशीट/माणप के
अनुसार िवालय/कॉलेज का
कू ल / कॉलेज का पता vedram colony
नाम (School/College name krishna public school
(School / College Address) ,sehatpur,faridabad,haryana,121003
should be as per Class
10th Mark
sheet/certificate)
कू ल / कॉलेज िपनकोड रोल नंबर 10वीं माणप के
(School / College 121003 अनुसार (Roll number as 1022154602
Pincode) per 10th certificate)
पिरणाम मोड (Result अिधकतम ग े ड वाइंट (Max
CGPA 10.0
Mode) Grade Point)
सीजीपीए ात िकया संचयी ितशत (Cumulative
8.8000000000000007 90.2
(Obtained CGPA) Percentage)
12वीं या समक योयता िववरण (12th or equivalent Qualification Details)
उीण / सिमिलत होने का
उीण की िथित (Pass
Appearing वष (Year of 2024
Status)
Passing/Appearing)
Any Public School/ Board/ University examination in India
योयता परीा (Qualifying or any foreign country is recognized as equivalent to the कू िलंग का थान (Place of
Urban
Exam) 10+2 system by the Association of Indian Universities Schooling)
(AIU).
योयता परीा राय
कू ल / कॉलेज का कार
Government School (Qualifying Examination HARYANA
(Type of School / College)
State)
योयता परीा िजला
HARYANA BOARD OF SCHOOL
(Qualifying Examination Faridabad कू ल बोड (School Board)
EDUCATION
District)
का 12वीं की
माकशीट/माणप के
अनुसार िवालय/कॉलेज का
कू ल / कॉलेज का पता sarai
नाम (School/College name government model senior secondary school
(School / College Address) khwaja,faridabad,haryana,121003
should be as per Class
12th Mark
sheet/certificate)
कू ल / कॉलेज िपनकोड रोल नंबर 12वीं माणप के
(School / College 121003 अनुसार (Roll number as NA
Pincode) 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 (Are you a Twin
NO
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
7678462552 ईमेल आईडी (Email ID) sjha91457@gmail.com
Number)
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
Online ZIC51568676315
Mode) (Transaction ID)
लेन-दे न की ितिथ (Date of
परीा शु क (Exam Fee) 2000.0 29-11-2023 16:23:04 PM
Transaction)
शु क जमा िकया गया (Fee
29-11-2023 16:21:08 PM
Submitted 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 : 106.196.42.247 Date of Downloading : 29-11-2023 16:23:28 PM