सं युत वे श परीा (मु य)

Joint Entrance Examination (Main)

JEE(Main)

APPLICATION NUMBER 240310028194

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)
SSG COACHING,
AMBEDKARNAGAR,
पता (Premises No/ Name) SHAKTINAGAR, ईमेल पता (Email Address) EKASHMANTIWARI@GMAIL.COM
SONBHADRA, UTTAR
PRADESH
उप-थानीयता (Sub-
थानीयता (Locality) SHAKTINAGAR AMBEDKARNAGAR
Locality)(Optional)
दे श कोड (Country Code) 91 दे श (Country) INDIA
राय (State) UTTAR PRADESH िजला (District) Sonbhadra
वै किपक संपक सू (Alternate
मोबाइल नंबर (Mobile Number) 91 - 9451626112 6306876199
Contact No.) (Optional)
िपन कोड (Pin Code) 231222
थायी पता (Permanent Address)
SSG COACHING,
AMBEDKARNAGAR,
पता (Premises No/ Name) SHAKTINAGAR, थानीयता (Locality) SHAKTINAGAR
SONBHADRA, UTTAR
PRADESH
उप-थानीयता (Sub-
AMBEDKARNAGAR दे श (Country) INDIA
Locality)(Optional):
राय (State) UTTAR PRADESH िजला (District) Sonbhadra
िपन कोड (Pin Code) 231222
यितगत योरा (PERSONAL DETAILS)
अयथी की जम ितिथ (Candidate's
अयथी का नाम (Candidate's Name) EKASHMAN TIWARI 24-03-2006
Date of Birth)
िपता / अिभभावक का नाम (Father / माता / अिभभावक का नाम (Mother /
ATUL DEO TIWARI VINITA TIWARI
Guardian Name) Guardian Name)
िलंग (Gender) MALE राटीयता (Nationality ) INDIAN
ANY OTHER VALID GOVT
पहचान संया (Identification
पहचान के कार (Identity Type) IDENTITY WITH 869822829853
Number)
PHOTOGRAPH
राय / केद शािसत दे श जहाँ से 12वीं /
समक उीण / उपिथत (State/ UT
UTTAR PRADESH े 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 400001-500000
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 2
(Session Of Exam Apply For)
िपता / अिभभावक यवसाय (Father / िपता / अिभभावक योयता (Father /
TEACHING / RESEARCH Post Graduate
Guardian Occupation) Guardian Qualification)
माता / अिभभावक यवसाय (Mother / माता / अिभभावक योयता (Mother /
Not Applicable POST GRADUATE
Guardian Occupation) Guardian Qualification)
परीा राय-पहला िवकप (Exam परीा शहर-पहला िवकप (Exam
UTTAR PRADESH VARANASI
State 1st Choice ) City 1st Choice )
परीा राय-दूसरा िवकप (Exam State परीा शहर-दूसरा िवकप (Exam
UTTAR PRADESH MAU
2nd Choice ) City 2nd Choice )
परीा राय-तीसरा िवकप (Exam परीा शहर-तीसरा िवकप (Exam
UTTAR PRADESH ALLAHABAD/PRAYAGRAJ
State 3rd Choice ) City 3rd Choice )
परीा राय-चौथा िवकप (Exam State परीा शहर-चौथा िवकप (Exam
UTTAR PRADESH LUCKNOW
4th Choice ) City 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 Rural
Schooling)
कू ल / कॉलेज का कार (Type of योयता परीा राय (Qualifying
Private Unaided UTTAR PRADESH
School / College) Examination State)
योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY
Sonbhadra कू ल बोड (School Board)
Examination District) EDUCATION
का 10वीं की माकशीट/माणप के
अनुसार िवालय/कॉलेज का नाम
st josephs school shakti ngr कू ल / कॉलेज का पता (School / vv colony ntpc shaktinagar, sonebhadra, uttar
(School/College name should be as
sonebhadra up College Address) pradesh
per Class 10th Mark
sheet/certificate)
रोल नंबर 10वीं माणप के अनुसार
कू ल / कॉलेज िपनकोड (School /
231222 (Roll number as per 10th 23264661
College Pincode)
certificate)
पिरणाम मोड (Result Mode) Percentage पूणा क (Total Marks) 500.0
ातांक (Obtain Marks) 482.0 ितशत (Percentage) 96.40
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) Rural
Board of Secondary Education, Schooling)
New Delhi; Council for the
Indian School Certificate
Examinations, New Delhi etc.
कू ल / कॉलेज का कार (Type of योयता परीा राय (Qualifying
Private Unaided UTTAR PRADESH
School / College) Examination State)
योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY
Sonbhadra कू ल बोड (School Board)
Examination District) EDUCATION
का 12वीं की माकशीट/माणप के
अनुसार िवालय/कॉलेज का नाम ST JOSEPHS SCHOOL
कू ल / कॉलेज का पता (School / VV COLONY NTPC SHAKTINAGAR,
(School/College name should be as SHAKTI NGR
College Address) SONEBHADRA, UTTAR PRADESH
per Class 12th Mark SONEBHADRA UP
sheet/certificate)
रोल नंबर 12वीं माणप के अनुसार
कू ल / कॉलेज िपनकोड (School /
231222 (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 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) 7607622582 ईमेल आईडी (Email ID) atuldeotiwari@gmail.com
उमीदवार ारा अपलोड की गई छिवयां (IMAGES UPLOADED BY THE CANDIDATE)

PHOTO
 SIGNATURE

शु क भु गतान िववरण (Fee Payment Details)

भु गतान का कार (Payment Mode) Online लेन-दे न आईडी (Transaction ID) CPADMNCLN9
लेन-दे न की ितिथ (Date of
परीा शु क (Exam Fee) 1000.0 04-02-2024 16:52:43 PM
Transaction)
शु क जमा िकया गया (Fee Submitted
04-02-2024 16:50:11 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 : 103.91.121.41 Date of Downloading : 04-02-2024 16:52:44 PM