सं युत वे श परीा (मु य)

Joint Entrance Examination (Main)

JEE(Main)
APPLICATION
240310079908
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)
ADARSH NAGAR
पता (Premises No/ Name) ईमेल पता (Email Address) SHANSHANTANUSINGH113@GMAIL.COM
AKOLWA
उप-थानीयता (Sub-
थानीयता (Locality) NATH MART NATH MART
Locality)(Optional)
दे श कोड (Country Code) 91 दे श (Country) INDIA
राय (State) UTTAR PRADESH िजला (District) Gorakhpur
वै किपक संपक सू (Alternate
मोबाइल नंबर (Mobile Number) 91 - 6388872153 9919613666
Contact No.) (Optional)
िपन कोड (Pin Code) 273014
थायी पता (Permanent Address)
पता (Premises No/ Name) GAYATRI NAGAR थानीयता (Locality) GAYATRI MANDIR
उप-थानीयता (Sub-
NA दे श (Country) INDIA
Locality)(Optional):
राय (State) UTTAR PRADESH िजला (District) Gorakhpur
िपन कोड (Pin Code) 273008
यितगत योरा (PERSONAL DETAILS)
अयथी की जम ितिथ
अयथी का नाम (Candidate's Name) SHANTANU SINGH 21-08-2006
(Candidate's Date of Birth)
िपता / अिभभावक का नाम (Father / RAM PRAKASH माता / अिभभावक का नाम (Mother
ANNAPURNA SINGH
Guardian Name) SINGH / Guardian Name)
िलंग (Gender) MALE राटीयता (Nationality ) INDIAN
ANY OTHER VALID
पहचान संया (Identification
पहचान के कार (Identity Type) GOVT IDENTITY 703753653398
Number)
WITH PHOTOGRAPH
राय / केद शािसत दे श जहाँ से 12वीं
/ समक उीण / उपिथत (State/ UT
UTTAR PRADESH े णी (Category ) GENERAL
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 है वािषक पािरवािरक आय ( Annual
NA 400001-500000
(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
Self-Study मायम ( Medium of schooling in English
Preparation )
qualifying exam )
परीा कद िववरण (Exam centre Details)
B. Planning, B.Arch., परीा के स के िलए आवे दन कर
के िलए आवे दन (Apply For) Session 1 & Session 2
B.E./B.Tech (Session Of Exam Apply For)
िपता / अिभभावक यवसाय (Father / GOVERNMENT िपता / अिभभावक योयता (Father /
Post Graduate
Guardian Occupation) SERVICE Guardian Qualification)
माता / अिभभावक यवसाय (Mother / माता / अिभभावक योयता (Mother
Others GRADUATE
Guardian Occupation) / Guardian Qualification)
परीा राय-पहला िवकप (Exam परीा शहर-पहला िवकप (Exam
UTTAR PRADESH GORAKHPUR
State 1st Choice ) City 1st Choice )
परीा राय-दूसरा िवकप (Exam परीा शहर-दूसरा िवकप (Exam
UTTAR PRADESH BASTI
State 2nd Choice ) City 2nd Choice )
परीा राय-तीसरा िवकप (Exam परीा शहर-तीसरा िवकप (Exam
UTTAR PRADESH AZAMGARH
State 3rd Choice ) City 3rd Choice )
परीा राय-चौथा िवकप (Exam परीा शहर-चौथा िवकप (Exam
UTTAR PRADESH LUCKNOW
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 की िथित (Pass Status)
योयता परीा (Qualifying Exam)
कू ल / कॉलेज का कार (Type of
School / College)
योयता परीा िजला (Qualifying
Examination District)
का 10वीं की माकशीट/माणप के
अनुसार िवालय/कॉलेज का नाम
(School/College name should be as
per Class 10th Mark
sheet/certificate)
कू ल / कॉलेज िपनकोड (School /
College Pincode)
पिरणाम मोड (Result Mode)
ातांक (Obtain Marks)
12वीं या समक योयता िववरण (12 or equivalent Qualification Details)
उीण की िथित (Pass Status)
योयता परीा (Qualifying Exam)
कू ल / कॉलेज का कार (Type of
School / College)
योयता परीा िजला (Qualifying
Examination District)
का 12वीं की माकशीट/माणप के
अनुसार िवालय/कॉलेज का नाम
(School/College name should be as
per Class 12th Mark
sheet/certificate)
कू ल / कॉलेज िपनकोड (School /
College Pincode)
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 JEE (MAIN) – NO
2024)?
आपातकालीन संपक िववरण प (Emergency Contact Details)
दे श (Country)
मोबाइल नंबर (Mobile Number)
उमीदवार ारा अपलोड की गई छिवयां (IMAGES UPLOADED BY THE CANDIDATE)
उीण / सिमिलत होने का वष (Year
Passed 2022
of Passing/Appearing)
कू िलंग का थान (Place of
10 th or equivalent Urban
Schooling)
योयता परीा राय (Qualifying
Kendriya vidayalya (KV) UTTAR PRADESH
Examination State)
CENTRAL BOARD OF SECONDARY
Gorakhpur कू ल बोड (School Board)
EDUCATION
कू ल / कॉलेज का पता (School /
shantanu singh kendriya vidyalaya afs gorakhpur
College Address)
रोल नंबर 10वीं माणप के अनुसार
273002 (Roll number as per 10th 23157751
certificate)
Percentage पूणा क (Total Marks) 500.0
398.0 ितशत (Percentage) 79.60
th
उीण / सिमिलत होने का वष (Year
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
Board of Secondary Urban
Schooling)
Education, New Delhi;
Council for the Indian
School Certificate
Examinations, New Delhi
etc.
योयता परीा राय (Qualifying
Kendriya vidayalya (KV) UTTAR PRADESH
Examination State)
CENTRAL BOARD OF SECONDARY
Gorakhpur कू ल बोड (School Board)
EDUCATION
कू ल / कॉलेज का पता (School /
shantanu singh kendriya vidyalaya afs gorakhapur
College Address)
रोल नंबर 12वीं माणप के अनुसार
273002 (Roll number as per 12th NA
certificate)
INDIA दे श कोड (Country Code) +91
7007150224 ईमेल आईडी (Email ID) lalanramprakash@gmail.com

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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) CPADFSNTO9
लेन-दे न की ितिथ (Date of
परीा शु क (Exam Fee) 4000.0 01-01-1900 00:00:00 AM
Transaction)
शु क जमा िकया गया (Fee Submitted
05-11-2023 21:39:26 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 : 223.182.252.36 Date of Downloading : 05-11-2023 21:48:28 PM