सं युत वे श परीा (मु य)

Joint Entrance Examination (Main)

JEE(Main)

APPLICATION NUMBER 240311182298

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)
VILL-KOTHILA KHAS
पता (Premises No/ Name) POST-SONHA DISTRICT- ईमेल पता (Email Address) VK791223@GMAIL.COM
BASTI PIN - 272190
थानीयता (Locality) BASTI उप-थानीयता (Sub-Locality)(Optional) BHANPUR
दे श कोड (Country Code) 91 दे श (Country) INDIA
राय (State) UTTAR PRADESH िजला (District) Basti
वै किपक संपक सू (Alternate Contact
मोबाइल नंबर (Mobile Number) 91 - 9919813765 7348757638
No.) (Optional)
िपन कोड (Pin Code) 272190
थायी पता (Permanent Address)
VILL-KOTHILA KHAS
पता (Premises No/ Name) POST-SONHA DISTRICT- थानीयता (Locality) BASTI
BASTI PIN - 272190
उप-थानीयता (Sub-
BHANPUR दे श (Country) INDIA
Locality)(Optional):
राय (State) UTTAR PRADESH िजला (District) Basti
िपन कोड (Pin Code) 272190
यितगत योरा (PERSONAL DETAILS)
अयथी की जम ितिथ (Candidate's Date
अयथी का नाम (Candidate's Name) BHANU PRATAP 26-04-2006
of Birth)
िपता / अिभभावक का नाम (Father / माता / अिभभावक का नाम (Mother /
DILEEP KUMAR SUBHAWATI DEVI
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) 557732229091
PHOTOGRAPH
राय / केद शािसत दे श जहाँ से 12वीं /
समक उीण / उपिथत (State/ UT
UTTAR PRADESH े णी (Category ) SC
from where 12th/ Equivalent Passed/
Appearing)
या आपको मधुमेह ह  (Are You
NO िनवास की जगह ( Place of Residence ) RURAL
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 300001-400000
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
Of Exam Apply For)
िपता / अिभभावक यवसाय (Father / िपता / अिभभावक योयता (Father /
GOVERNMENT SERVICE Graduate
Guardian Occupation) Guardian Qualification)
माता / अिभभावक यवसाय (Mother / माता / अिभभावक योयता (Mother /
Not Applicable ILLITERATE
Guardian Occupation) Guardian Qualification)
परीा राय-पहला िवकप (Exam State परीा शहर-पहला िवकप (Exam City 1st
UTTAR PRADESH BASTI
1st Choice ) Choice )
परीा राय-दूसरा िवकप (Exam State परीा शहर-दूसरा िवकप (Exam City 2nd
UTTAR PRADESH GORAKHPUR
2nd Choice ) Choice )
परीा राय-तीसरा िवकप (Exam State परीा शहर-तीसरा िवकप (Exam City 3rd
UTTAR PRADESH FAIZABAD
3rd Choice ) Choice )
परीा राय-चौथा िवकप (Exam State परीा शहर-चौथा िवकप (Exam City 4th
UTTAR PRADESH AMBEDKAR NAGAR
4th Choice ) 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 (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) Rural
कू ल / कॉलेज का कार (Type of School / Jawahar Navodaya योयता परीा राय (Qualifying
UTTAR PRADESH
College) Vidyalaya (JNVs) Examination State)
योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY
Basti कू ल बोड (School Board)
Examination District) EDUCATION
का 10वीं की माकशीट/माणप के
अनुसार िवालय/कॉलेज का नाम Jawahar navodaya vidyalaya कू ल / कॉलेज का पता (School / College
bahadurpur rudhauli basti
(School/College name should be as per bahadurpur basti up Address)
Class 10th Mark sheet/certificate)
कू ल / कॉलेज िपनकोड (School / College रोल नंबर 10वीं माणप के अनुसार (Roll
272151 23129344
Pincode) number as per 10th certificate)
पिरणाम मोड (Result Mode) Percentage पूणा क (Total Marks) 500.0
ातांक (Obtain Marks) 416.0 ितशत (Percentage) 83.20
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)
The final examination of the
10+2 system, conducted by
any recognized Central/
State Board, such as the
Central Board of Secondary
योयता परीा (Qualifying Exam) कू िलंग का थान (Place of Schooling) Rural
Education, New Delhi;
Council for the Indian
School Certificate
Examinations, New Delhi
etc.
कू ल / कॉलेज का कार (Type of School / Jawahar Navodaya योयता परीा राय (Qualifying
UTTAR PRADESH
College) Vidyalaya (JNVs) Examination State)
योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY
Basti कू ल बोड (School Board)
Examination District) EDUCATION
का 12वीं की माकशीट/माणप के JAWAHAR NAVODAYA
अनुसार िवालय/कॉलेज का नाम VIDYALAYA कू ल / कॉलेज का पता (School / College
BAHADURPUR RUDHAULI BASTI
(School/College name should be as per BAHADURPUR BASTI Address)
Class 12th Mark sheet/certificate) UP
कू ल / कॉलेज िपनकोड (School / College रोल नंबर 12वीं माणप के अनुसार (Roll
272151 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) 9335524327 ईमेल आईडी (Email ID) mishraankurs629@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) Online लेन-दे न आईडी (Transaction ID) CPADHHQND6
परीा शु क (Exam Fee) 500.0 लेन-दे न की ितिथ (Date of Transaction) 01-01-1900 00:00:00 AM
शु क जमा िकया गया (Fee Submitted
28-11-2023 19:05:59 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 : 47.15.159.205 Date of Downloading : 28-11-2023 19:07:51 PM