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THE CANDIDATE IS REQUESTED TO RETAIN THE PRINTOUT OF THE CONFIRMATION PAGE FOR FUTURE REFERENCE. यितगत योरा (Contact Details) वतमान पता (Present Address) पता (Premises No/ Name) 47 ईमेल पता (Email Address) ANANDYADAV17787@GMAIL.COM उप-थानीयता (Sub- थानीयता (Locality) LACHHEHARA LACHHEHARA Locality)(Optional) दे श कोड (Country Code) 91 दे श (Country) INDIA राय (State) UTTAR PRADESH िजला (District) Azamgarh वै किपक संपक सू (Alternate मोबाइल नंबर (Mobile Number) 91 - 8470884205 9452104705 Contact No.) (Optional) िपन कोड (Pin Code) 276141 थायी पता (Permanent Address) पता (Premises No/ Name) 47 थानीयता (Locality) LACHHEHARA उप-थानीयता (Sub- LACHHEHARA दे श (Country) INDIA Locality)(Optional): राय (State) UTTAR PRADESH िजला (District) Azamgarh िपन कोड (Pin Code) 276141 यितगत योरा (PERSONAL DETAILS) अयथी की जम ितिथ (Candidate's अयथी का नाम (Candidate's Name) ANAND YADAV 20-10-2005 Date of Birth) िपता / अिभभावक का नाम (Father / माता / अिभभावक का नाम (Mother / PRAMOD YADAV KUSUM YADAV Guardian Name) Guardian Name) िलंग (Gender) MALE राटीयता (Nationality ) INDIAN ANY OTHER VALID पहचान संया (Identification पहचान के कार (Identity Type) GOVT IDENTITY WITH 334179254026 Number) PHOTOGRAPH राय / केद शािसत दे श जहाँ से 12वीं / समक उीण / उपिथत (State/ UT UTTAR PRADESH े णी (Category ) OBC-(NCL) AS PER CENTRAL LIST 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 उमीदवार ह , तो या आपके पास ब चमाक िवकलांगता है (If you वािषक पािरवािरक आय ( Annual NA 0-100000 are a Pwd Candidate, do you have Family Income ) benchmark disability)? योयता परीा म कू ली िशा का तैयारी का तरीका ( Mode of Preparation Self-Study मायम ( Medium of schooling in English ) qualifying exam ) परीा कद िववरण (Exam centre Details) परीा 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 / िपता / अिभभावक योयता (Father / OTHERS Graduate Guardian Occupation) Guardian Qualification) माता / अिभभावक यवसाय (Mother / माता / अिभभावक योयता (Mother / Not Applicable POST GRADUATE Guardian Occupation) Guardian Qualification) परीा राय-पहला िवकप (Exam State परीा शहर-पहला िवकप (Exam UTTAR PRADESH AZAMGARH 1st Choice ) City 1st Choice ) परीा राय-दूसरा िवकप (Exam State परीा शहर-दूसरा िवकप (Exam City UTTAR PRADESH VARANASI 2nd Choice ) 2nd Choice ) परीा राय-तीसरा िवकप (Exam State परीा शहर-तीसरा िवकप (Exam UTTAR PRADESH LUCKNOW 3rd Choice ) City 3rd Choice ) परीा राय-चौथा िवकप (Exam State परीा शहर-चौथा िवकप (Exam City UTTAR PRADESH GORAKHPUR 4th Choice ) 4th Choice ) न प मायम (Question Paper Medium) English 10वीं या समक योयता िववरण (10th or equivalent Qualification Details) उीण / सिमिलत होने का वष (Year उीण की िथित (Pass Status) Passed 2021 of Passing/Appearing) कू िलंग का थान (Place of योयता परीा (Qualifying Exam) 10 th or equivalent Rural Schooling) कू ल / कॉलेज का कार (Type of School योयता परीा राय (Qualifying Private Unaided UTTAR PRADESH / College) Examination State) योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY Azamgarh कू ल बोड (School Board) Examination District) EDUCATION का 10वीं की माकशीट/माणप के अनुसार िवालय/कॉलेज का नाम shri durgaji public sch vil कू ल / कॉलेज का पता (School / sehda , sadar , azamgarh (School/College name should be as sehda sadar azamgarh College Address) per Class 10th Mark sheet/certificate) रोल नंबर 10वीं माणप के अनुसार कू ल / कॉलेज िपनकोड (School / College 236135 (Roll number as per 10th 23106969 Pincode) certificate) पिरणाम मोड (Result Mode) Percentage पूणा क (Total Marks) 500.0 ातांक (Obtain Marks) 454.0 ितशत (Percentage) 90.80 th 12वीं या समक योयता िववरण (12 or equivalent Qualification Details) उीण / सिमिलत होने का वष (Year उीण की िथित (Pass Status) Passed 2023 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 योयता परीा (Qualifying Exam) Board of Secondary Rural Schooling) Education, New Delhi; Council for the Indian School Certificate Examinations, New Delhi etc. कू ल / कॉलेज का कार (Type of School योयता परीा राय (Qualifying Private Unaided UTTAR PRADESH / College) Examination State) योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY Azamgarh कू ल बोड (School Board) Examination District) EDUCATION का 12वीं की माकशीट/माणप के SHRI DURGAJI PUBLIC अनुसार िवालय/कॉलेज का नाम कू ल / कॉलेज का पता (School / SCH VIL SEHDA SADAR SEHDA , SADAR , AZAMGARH (School/College name should be as College Address) AZAMGARH per Class 12th Mark sheet/certificate) रोल नंबर 12वीं माणप के अनुसार कू ल / कॉलेज िपनकोड (School / College 236135 (Roll number as per 12th 23613315 Pincode) certificate) पिरणाम मोड (Result Mode) Percentage पूणा क (Total Marks) 500.0 ातांक (Obtain Marks) 415.0 ितशत (Percentage) 83.00 अितिरत 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) 8858544533 ईमेल आईडी (Email ID) pramodumangyadav@gmail.com उमीदवार ारा अपलोड की गई छिवयां (IMAGES UPLOADED BY THE CANDIDATE)
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भु गतान का कार (Payment Mode) Online लेन-दे न आईडी (Transaction ID) CPADNJMHD4 लेन-दे न की ितिथ (Date of परीा शु क (Exam Fee) 900.0 15-02-2024 19:45:24 PM Transaction) शु क जमा िकया गया (Fee Submitted 15-02-2024 19:43:43 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 : 152.58.130.25 Date of Downloading : 15-02-2024 19:49:27 PM