सं युत वे श परीा (मु य)

Joint Entrance Examination (Main)

JEE(Main)

APPLICATION NUMBER 240310788077

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)
QUARTER NO. - 52,
पता (Premises No/ Name) SECTOR - C, ईमेल पता (Email Address) PRAKASH2005DEEP@GMAIL.COM
BONDAMUNDA
उप-थानीयता (Sub-
थानीयता (Locality) BONDAMUNDA SECTOR - C
Locality)(Optional)
दे श कोड (Country Code) 91 दे श (Country) INDIA
राय (State) ODISHA िजला (District) Sundargarh
वै किपक संपक सू (Alternate
मोबाइल नंबर (Mobile Number) 91 - 8249105583 7008493584
Contact No.) (Optional)
िपन कोड (Pin Code) 770032
थायी पता (Permanent Address)
S/O- DEVENDRA
पता (Premises No/ Name) KUMAR, VILLAGE- थानीयता (Locality) RAMPUR
UDAIPUR, PO- RAMPUR
उप-थानीयता (Sub-
UDAIPUR दे श (Country) INDIA
Locality)(Optional):
राय (State) UTTAR PRADESH िजला (District) Ballia
िपन कोड (Pin Code) 277207
यितगत योरा (PERSONAL DETAILS)
अयथी की जम ितिथ (Candidate's
अयथी का नाम (Candidate's Name) PRAKASH DEEP 09-11-2005
Date of Birth)
िपता / अिभभावक का नाम (Father / माता / अिभभावक का नाम (Mother /
DEVENDRA KUMAR SALITA DEVI
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 666205858480
Number)
PHOTOGRAPH
राय / केद शािसत दे श जहाँ से 12वीं /
समक उीण / उपिथत (State/ UT
ODISHA े णी (Category ) SC
from where 12th/ Equivalent Passed/
Appearing)
या आपको मधुमेह ह  (Are You िनवास की जगह ( Place of Residence
NO RURAL
Diabetic ? ) )
यिद आप एक Pwd उमीदवार ह , तो या
आपके पास ब चमाक िवकलांगता है (If you वािषक पािरवािरक आय ( Annual
NA 700001-800000
are a Pwd Candidate, do you have Family Income )
benchmark disability)?
योयता परीा म कू ली िशा का
तैयारी का तरीका ( Mode of Preparation
Self-Study मायम ( Medium of schooling in English
)
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 2
(Session Of Exam Apply For)
िपता / अिभभावक यवसाय (Father / GOVERNMENT िपता / अिभभावक योयता (Father /
Matriculate
Guardian Occupation) SERVICE Guardian Qualification)
माता / अिभभावक यवसाय (Mother / माता / अिभभावक योयता (Mother /
Not Applicable OTHERS
Guardian Occupation) Guardian Qualification)
परीा राय-पहला िवकप (Exam State परीा शहर-पहला िवकप (Exam City
ODISHA ROURKELA
1st Choice ) 1st Choice )
परीा राय-दूसरा िवकप (Exam State परीा शहर-दूसरा िवकप (Exam City
nd ODISHA nd JHARSUGUDA
2 Choice ) 2 Choice )
परीा राय-तीसरा िवकप (Exam State परीा शहर-तीसरा िवकप (Exam
ODISHA SAMBALPUR
3rd Choice ) City 3rd Choice )
परीा राय-चौथा िवकप (Exam State परीा शहर-चौथा िवकप (Exam City
ODISHA BHUBANESWAR
4th Choice ) 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 (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
Kendriya vidayalya (KV) ODISHA
College) Examination State)
योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY
Sundargarh कू ल बोड (School Board)
Examination District) EDUCATION
का 10वीं की माकशीट/माणप के
अनुसार िवालय/कॉलेज का नाम कू ल / कॉलेज का पता (School / SECTOR- A, BONDAMUNDA, DISTRICT-
K V BONDAMUNDA
(School/College name should be as per College Address) SUNDARGARH
Class 10th Mark sheet/certificate)
रोल नंबर 10वीं माणप के अनुसार
कू ल / कॉलेज िपनकोड (School / College
770032 (Roll number as per 10th 12181168
Pincode)
certificate)
पिरणाम मोड (Result Mode) Percentage पूणा क (Total Marks) 500.0
ातांक (Obtain Marks) 459.0 ितशत (Percentage) 91.80
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 Board of Secondary कू िलंग का थान (Place of
योयता परीा (Qualifying Exam) Urban
Education, New Delhi; Schooling)
Council for the Indian
School Certificate
Examinations, New Delhi
etc.
कू ल / कॉलेज का कार (Type of School / योयता परीा राय (Qualifying
Kendriya vidayalya (KV) ODISHA
College) Examination State)
योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY
Sundargarh कू ल बोड (School Board)
Examination District) EDUCATION
का 12वीं की माकशीट/माणप के
अनुसार िवालय/कॉलेज का नाम कू ल / कॉलेज का पता (School / SECTOR- A BONDAMUNDA, DISTRICT-
K V BONDAMUNDA
(School/College name should be as per College Address) SUNDARGARH
Class 12th Mark sheet/certificate)
रोल नंबर 12वीं माणप के अनुसार
कू ल / कॉलेज िपनकोड (School / College
770032 (Roll number as per 12th NA
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 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) 7008667566 ईमेल आईडी (Email ID) kumarprabhat097@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) CPADGWYMB1
लेन-दे न की ितिथ (Date of
परीा शु क (Exam Fee) 1000.0 01-01-1900 00:00:00 AM
Transaction)
शु क जमा िकया गया (Fee Submitted
22-11-2023 21:21:58 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 : 106.200.246.22 Date of Downloading : 08-02-2024 14:46:59 PM