JEE(Main) APPLICATION 240310841024 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. यितगत योरा (Contact Details) वतमान पता (Present Address) 5-126,REDDY REDDY पता (Premises No/ Name) ईमेल पता (Email Address) SVPUBLICSCHOOL2001@GMAIL.COM COLONY VEDURUKUPPAM उप-थानीयता (Sub- थानीयता (Locality) PACHIKAPALLAM POST MANDAL Locality)(Optional) दे श कोड (Country Code) +91 दे श (Country) INDIA राय (State) ANDHRA PRADESH िजला (District) Chittoor वै किपक संपक सू (Alternate मोबाइल नंबर (Mobile Number) +91 - 9704317615 9642808288 Contact No.) (Optional) िपन कोड (Pin Code) 517569 थायी पता (Permanent Address) 5-126,REDDY REDDY पता (Premises No/ Name) थानीयता (Locality) VEDURUKUPPAM MANDAL COLONY उप-थानीयता (Sub- PACHIKAPALLAM POST दे श (Country) INDIA Locality)(Optional): राय (State) ANDHRA PRADESH िजला (District) Chittoor िपन कोड (Pin Code) 517569 यितगत योरा (PERSONAL DETAILS) KATARI अयथी की जम ितिथ (Candidate's अयथी का नाम (Candidate's Name) HARSHAVARDHAN 04-01-2007 Date of Birth) REDDY िपता / अिभभावक का नाम (Father / माता / अिभभावक का नाम (Mother / KATARI SRIHARI BANDI REVATHI Guardian Name) Guardian Name) िलंग (Gender) MALE राटीयता (Nationality ) INDIAN ANY OTHER VALID पहचान संया (Identification पहचान के कार (Identity Type) GOVT IDENTITY WITH 223773319167 Number) PHOTOGRAPH राय / केद शािसत दे श जहाँ से 12वीं / समक उीण / उपिथत (State/ UT ANDHRA PRADESH े णी (Category ) GEN-EWS 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 उमीदवार ह , तो या आपके पास ब चमाक िवकलांगता है (If वािषक पािरवािरक आय ( Annual NA 0-100000 you are a Pwd Candidate, do you Family Income ) have benchmark disability)? योयता परीा म कू ली िशा का तैयारी का तरीका ( Mode of Self-Study मायम ( Medium of schooling in English Preparation ) 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 / AGRICULTURE Post Graduate Guardian Occupation) Guardian Qualification) माता / अिभभावक यवसाय (Mother / माता / अिभभावक योयता (Mother Others GRADUATE Guardian Occupation) / Guardian Qualification) परीा राय-पहला िवकप (Exam परीा शहर-पहला िवकप (Exam ANDHRA PRADESH TIRUPATHI State 1st Choice ) City 1st Choice ) परीा राय-दूसरा िवकप (Exam परीा शहर-दूसरा िवकप (Exam ANDHRA PRADESH PUTTUR AP State 2nd Choice ) City 2nd Choice ) परीा राय-तीसरा िवकप (Exam परीा शहर-तीसरा िवकप (Exam ANDHRA PRADESH CHITTOOR State 3rd Choice ) City 3rd Choice ) परीा राय-चौथा िवकप (Exam परीा शहर-चौथा िवकप (Exam ANDHRA PRADESH NELLORE State 4th Choice ) City 4th Choice ) न प मायम (Question Paper Medium) English th 10वीं या समक योयता िववरण (10 or equivalent Qualification Details) उीण / सिमिलत होने का वष (Year उीण की िथित (Pass Status) Passed 2022 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 योयता परीा राय (Qualifying Private Unaided ANDHRA PRADESH School / College) Examination State) योयता परीा िजला (Qualifying ANDHRA PRADESH BOARD OF Chittoor कू ल बोड (School Board) Examination District) SECONDARY EDUCATION का 10वीं की माकशीट/माणप के अनुसार िवालय/कॉलेज का नाम कू ल / कॉलेज का पता (School / (School/College name should be as S V PUBLIC SCHOOL PACHIKAPALLAM,CHITTOOR DISTRICT College Address) per Class 10th Mark sheet/certificate) रोल नंबर 10वीं माणप के अनुसार कू ल / कॉलेज िपनकोड (School / 517569 (Roll number as per 10th 2219128329 College Pincode) certificate) पिरणाम मोड (Result Mode) Percentage पूणा क (Total Marks) 600.0 ातांक (Obtain Marks) 521.0 ितशत (Percentage) 86.83 th 12वीं या समक योयता िववरण (12 or equivalent Qualification Details) उीण / सिमिलत होने का वष (Year उीण की िथित (Pass Status) Appearing 2024 of Passing/Appearing) Intermediate or two-year Pre-University examination कू िलंग का थान (Place of योयता परीा (Qualifying Exam) Urban conducted by a recognized Schooling) Board/ University. कू ल / कॉलेज का कार (Type of योयता परीा राय (Qualifying Private Unaided ANDHRA PRADESH School / College) Examination State) योयता परीा िजला (Qualifying ANDHRA PRADESH BOARD OF Tirupati कू ल बोड (School Board) Examination District) INTERMEDIATE EDUCATION का 12वीं की माकशीट/माणप के अनुसार िवालय/कॉलेज का नाम SRIDHARS JUNIOR कू ल / कॉलेज का पता (School / (School/College name should be as TIRUPATI COLLEGE College Address) per Class 12th Mark sheet/certificate) रोल नंबर 12वीं माणप के अनुसार कू ल / कॉलेज िपनकोड (School / 517501 (Roll number as per 12th NA College Pincode) certificate) 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) 9110364580 ईमेल आईडी (Email ID) hareeshthayyuru45@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) CPADNAFET5 लेन-दे न की ितिथ (Date of परीा शु क (Exam Fee) 900.0 12-02-2024 09:59:36 AM Transaction) शु क जमा िकया गया (Fee Submitted 12-02-2024 09:57:39 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 : 157.47.43.165 Date of Downloading : 12-02-2024 10:00:25 AM