सं युत वे श परीा (मु य)

Joint Entrance Examination (Main)

JEE(Main)

APPLICATION NUMBER 240310611096

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यितगत योरा (Contact Details) वतमान पता (Present Address)
B-23 RATILAL PARK
OPP DEVKINANDAN
पता (Premises No/ Name) ईमेल पता (Email Address) NAMITAPAREKH@YAHOO.COM
DERASAR DARPAN
FIVE ROADS
उप-थानीयता (Sub-
थानीयता (Locality) NAVRANGPURA NA
Locality)(Optional)
दे श कोड (Country Code) 91 दे श (Country) INDIA
राय (State) GUJARAT िजला (District) Ahmadabad
वै किपक संपक सू (Alternate Contact
मोबाइल नंबर (Mobile Number) 91 - 9408784245 NA
No.) (Optional)
िपन कोड (Pin Code) 380014
थायी पता (Permanent Address)
B-23 RATILAL PARK
OPP DEVKINANDAN
पता (Premises No/ Name) थानीयता (Locality) NAVRANGPURA
DERASAR DARPAN
FIVE ROADS
उप-थानीयता (Sub-
NA दे श (Country) INDIA
Locality)(Optional):
राय (State) GUJARAT िजला (District) Ahmadabad
िपन कोड (Pin Code) 380014
यितगत योरा (PERSONAL DETAILS)
PAREKH JAY अयथी की जम ितिथ (Candidate's
अयथी का नाम (Candidate's Name) 03-07-2007
DARSHANBHAI Date of Birth)
िपता / अिभभावक का नाम (Father / माता / अिभभावक का नाम (Mother /
PAREKH DARSHAN PAREKH NAMITA
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 654183141784
Number)
PHOTOGRAPH
राय / केद शािसत दे श जहाँ से 12वीं /
समक उीण / उपिथत (State/ UT
GUJARAT े णी (Category ) GENERAL
from where 12th/ Equivalent Passed/
Appearing)
या आपको मधुमेह ह  (Are You
NO िनवास की जगह ( Place of Residence ) URBAN
Diabetic ? )
यिद आप एक Pwd उमीदवार ह , तो या
आपके पास ब चमाक िवकलांगता है (If you वािषक पािरवािरक आय ( Annual
NA 100001-200000
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
Others 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 Of Exam Apply For)
िपता / अिभभावक यवसाय (Father / िपता / अिभभावक योयता (Father /
PRIVATE SERVICE Post Graduate
Guardian Occupation) Guardian Qualification)
माता / अिभभावक यवसाय (Mother / माता / अिभभावक योयता (Mother /
Others POST GRADUATE
Guardian Occupation) Guardian Qualification)
परीा राय-पहला िवकप (Exam State परीा शहर-पहला िवकप (Exam City
GUJARAT AHMEDABAD
1st Choice ) 1st Choice )
परीा राय-दूसरा िवकप (Exam State परीा शहर-दूसरा िवकप (Exam City
GUJARAT GANDHINAGAR
2nd Choice ) 2nd Choice )
परीा राय-तीसरा िवकप (Exam State परीा शहर-तीसरा िवकप (Exam City
GUJARAT VADODARA
3rd Choice ) 3rd Choice )
परीा राय-चौथा िवकप (Exam State परीा शहर-चौथा िवकप (Exam City
GUJARAT MEHSANA
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 of
उीण की िथित (Pass Status) Passed 2022
Passing/Appearing)
योयता परीा (Qualifying Exam) 10 th or equivalent कू िलंग का थान (Place of Schooling) Urban
कू ल / कॉलेज का कार (Type of School / योयता परीा राय (Qualifying
Government Aided Private GUJARAT
College) Examination State)
योयता परीा िजला (Qualifying GUJARAT SECONDARY & HIGHER
Ahmadabad कू ल बोड (School Board)
Examination District) SECONDARY EDUCATION BOARD
का 10वीं की माकशीट/माणप के
अनुसार िवालय/कॉलेज का नाम कू ल / कॉलेज का पता (School / st xaviers high school loyola hall, naranpura
parekh jay darshanbhai
(School/College name should be as per College Address) ahmedabad
Class 10th Mark sheet/certificate)
कू ल / कॉलेज िपनकोड (School / College रोल नंबर 10वीं माणप के अनुसार
380013 a4027202
Pincode) (Roll number as per 10th certificate)
पिरणाम मोड (Result Mode) Percentage पूणा क (Total Marks) 600.0
ातांक (Obtain Marks) 513.0 ितशत (Percentage) 85.50
th
12वीं या समक योयता िववरण (12 or equivalent Qualification Details)
उीण / सिमिलत होने का वष (Year of
उीण की िथित (Pass Status) Appearing 2024
Passing/Appearing)
The final examination of
the 10+2 system, conducted
by any recognized Central/
State Board, such as the
Central Board of Secondary
योयता परीा (Qualifying Exam) कू िलंग का थान (Place of Schooling) Urban
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 GUJARAT
College) Examination State)
योयता परीा िजला (Qualifying GUJARAT SECONDARY & HIGHER
Ahmadabad कू ल बोड (School Board)
Examination District) SECONDARY EDUCATION BOARD
का 12वीं की माकशीट/माणप के
अनुसार िवालय/कॉलेज का नाम कू ल / कॉलेज का पता (School /
parekh jay darshanbhai s s divine school opp science city sola
(School/College name should be as per College Address)
Class 12th Mark sheet/certificate)
कू ल / कॉलेज िपनकोड (School / College रोल नंबर 12वीं माणप के अनुसार
380060 NA
Pincode) (Roll number as per 12th 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) 9898048257 ईमेल आईडी (Email ID) namitaparekh1977@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) 783208
लेन-दे न की ितिथ (Date of
परीा शु क (Exam Fee) 1000.0 18-11-2023 15:31:09 PM
Transaction)
शु क जमा िकया गया (Fee Submitted
18-11-2023 15:30:26 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 : 152.58.35.32 Date of Downloading : 22-02-2024 17:01:57 PM