सं युत वे श परीा (मु य)

Joint Entrance Examination (Main)

JEE(Main)

APPLICATION NUMBER 240311295904

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)
पता (Premises No/ Name) JEUGHALE WASTI ईमेल पता (Email Address) SHIVAMJEUGHALE546@GMAIL.COM
उप-थानीयता (Sub-
थानीयता (Locality) VINCHUR SUBHASHNAGAR ROAD
Locality)(Optional)
दे श कोड (Country Code) +91 दे श (Country) INDIA
राय (State) MAHARASHTRA िजला (District) Nashik
वै किपक संपक सू (Alternate
मोबाइल नंबर (Mobile Number) +91 - 9130137212 9552057154
Contact No.) (Optional)
िपन कोड (Pin Code) 422305
थायी पता (Permanent Address)
पता (Premises No/ Name) JEUGHALE WASTI थानीयता (Locality) VINCHUR
उप-थानीयता (Sub- SUBHASHNAGAR
दे श (Country) INDIA
Locality)(Optional): ROAD
राय (State) MAHARASHTRA िजला (District) Nashik
िपन कोड (Pin Code) 422305
यितगत योरा (PERSONAL DETAILS)
SHIVAM ASTIK अयथी की जम ितिथ (Candidate's
अयथी का नाम (Candidate's Name) 15-05-2006
JEUGHALE Date of Birth)
िपता / अिभभावक का नाम (Father / माता / अिभभावक का नाम (Mother /
ASTIK KAVITA
Guardian Name) Guardian Name)
िलंग (Gender) MALE राटीयता (Nationality ) INDIAN
ANY OTHER VALID
पहचान संया (Identification
पहचान के कार (Identity Type) GOVT IDENTITY WITH 883125830204
Number)
PHOTOGRAPH
राय / केद शािसत दे श जहाँ से 12वीं /
समक उीण / उपिथत (State/ UT
MAHARASHTRA े णी (Category ) GENERAL
from where 12th/ Equivalent Passed/
Appearing)
या आपको मधुमेह ह  (Are You िनवास की जगह ( Place of
NO RURAL
Diabetic ? ) Residence )
यिद आप एक Pwd उमीदवार ह , तो या
आपके पास ब चमाक िवकलांगता है (If वािषक पािरवािरक आय ( Annual
NA 0-100000
you are a Pwd Candidate, do you Family Income )
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)
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 यवसाय (Father / िपता / अिभभावक योयता (Father /
AGRICULTURE Others
Guardian Occupation) Guardian Qualification)
माता / अिभभावक यवसाय (Mother / माता / अिभभावक योयता (Mother /
Agriculture OTHERS
Guardian Occupation) Guardian Qualification)
परीा राय-पहला िवकप (Exam State परीा शहर-पहला िवकप (Exam
MAHARASHTRA NASHIK
1st Choice ) City 1st Choice )
परीा राय-दूसरा िवकप (Exam State परीा शहर-दूसरा िवकप (Exam
MAHARASHTRA AHMEDNAGAR
2nd Choice ) City 2nd Choice )
परीा राय-तीसरा िवकप (Exam परीा शहर-तीसरा िवकप (Exam
MAHARASHTRA AURANGABAD(MAHARASHTRA)
State 3rd Choice ) City 3rd Choice )
परीा राय-चौथा िवकप (Exam State परीा शहर-चौथा िवकप (Exam
MAHARASHTRA PUNE
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 / सिमिलत होने का वष (Year
उीण की िथित (Pass Status) Passed 2022
of Passing/Appearing)
कू िलंग का थान (Place of
योयता परीा (Qualifying Exam) 10 th or equivalent Urban
Schooling)
कू ल / कॉलेज का कार (Type of School योयता परीा राय (Qualifying
Private Unaided MAHARASHTRA
/ College) Examination State)
योयता परीा िजला (Qualifying MAHARASHTRA STATE BOARD OF SEC.
Nashik कू ल बोड (School Board)
Examination District) & HR. SECONDARY EDUCATION
का 10वीं की माकशीट/माणप के
अनुसार िवालय/कॉलेज का नाम
Karmveer Bhaurao Patil कू ल / कॉलेज का पता (School / Vinchur, Tal.Niphad, Dist, Vinchur,
(School/College name should be as
Vidyalaya, Vinchur College Address) Maharashtra 422305
per Class 10th Mark
sheet/certificate)
रोल नंबर 10वीं माणप के अनुसार
कू ल / कॉलेज िपनकोड (School /
422305 (Roll number as per 10th d067881
College Pincode)
certificate)
पिरणाम मोड (Result Mode) Percentage पूणा क (Total Marks) 500.0
ातांक (Obtain Marks) 369.0 ितशत (Percentage) 73.80
th
12वीं या समक योयता िववरण (12 or equivalent Qualification Details)
उीण / सिमिलत होने का वष (Year
उीण की िथित (Pass Status) 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
योयता परीा (Qualifying Exam) Board of Secondary Urban
Schooling)
Education, New Delhi;
Council for the Indian
School Certificate
Examinations, New Delhi
etc.
कू ल / कॉलेज का कार (Type of School योयता परीा राय (Qualifying
Private Unaided MAHARASHTRA
/ College) Examination State)
योयता परीा िजला (Qualifying MAHARASHTRA STATE BOARD OF SEC.
Ahmednagar कू ल बोड (School Board)
Examination District) & HR. SECONDARY EDUCATION
का 12वीं की माकशीट/माणप के
अनुसार िवालय/कॉलेज का नाम
K. B. Rohamare Junior कू ल / कॉलेज का पता (School / W7WW+86G, Chas, Manjur, Maharashtra
(School/College name should be as
College Chasnali College Address) 423604
per Class 12th Mark
sheet/certificate)
रोल नंबर 12वीं माणप के अनुसार
कू ल / कॉलेज िपनकोड (School /
423604 (Roll number as per 12th NA
College Pincode)
certificate)
अितिरत जानकािरयां (Additional Details)
या आप जु ड़वा ह और दोनों जे ईई (मे न) - 2024 के िलए आवे दन कर रहे
NO
ह (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) 9511850085 ईमेल आईडी (Email ID) shivrampitil@gmail.com
उमीदवार ारा अपलोड की गई छिवयां (IMAGES UPLOADED BY THE CANDIDATE)

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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) 84225192928
लेन-दे न की ितिथ (Date of
परीा शु क (Exam Fee) 1000.0 30-11-2023 09:14:14 AM
Transaction)
शु क जमा िकया गया (Fee Submitted
30-11-2023 09:12:48 AM
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 : 106.210.183.11 Date of Downloading : 30-11-2023 09:21:49 AM