सं युत वे श परीा (मु य)

Joint Entrance Examination (Main)

JEE(Main)
APPLICATION
240311328793
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.
यितगत योरा (Contact Details) वतमान पता (Present Address)
GOKUL DHAM
पता (Premises No/ Name) ईमेल पता (Email Address) RAHULSINGHRAWAT9950@GMAIL.COM
ENCLAVE D-16
उप-थानीयता (Sub-
थानीयता (Locality) NASIRABAD NEAR HOSUING BOARD
Locality)(Optional)
दे श कोड (Country Code) 91 दे श (Country) INDIA
राय (State) RAJASTHAN िजला (District) Ajmer
वै किपक संपक सू (Alternate
मोबाइल नंबर (Mobile Number) 91 - 9950961368 9358935201
Contact No.) (Optional)
िपन कोड (Pin Code) 305601
थायी पता (Permanent Address)
GOKUL DHAM
पता (Premises No/ Name) थानीयता (Locality) NASIRABAD
ENCLAVE D-16
उप-थानीयता (Sub- NEAR HOSUING
दे श (Country) INDIA
Locality)(Optional): BOARD
राय (State) RAJASTHAN िजला (District) Ajmer
िपन कोड (Pin Code) 305601
यितगत योरा (PERSONAL DETAILS)
अयथी की जम ितिथ (Candidate's
अयथी का नाम (Candidate's Name) RAHUL SINGH 28-08-2006
Date of Birth)
िपता / अिभभावक का नाम (Father / माता / अिभभावक का नाम (Mother /
POLU SINGH SHEELA 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 631643123492
Number)
PHOTOGRAPH
राय / केद शािसत दे श जहाँ से 12वीं /
समक उीण / उपिथत (State/ UT
RAJASTHAN े 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
NO URBAN
Diabetic ? ) Residence )
यिद आप एक Pwd उमीदवार ह , तो या
आपके पास ब चमाक िवकलांगता है (If वािषक पािरवािरक आय ( Annual
NA 800000 AND ABOVE
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 Of Exam Apply For)
िपता / अिभभावक यवसाय (Father / DEFENCE SERVICES िपता / अिभभावक योयता (Father /
Others
Guardian Occupation) (ARMY , NAVY, IAF) Guardian Qualification)
माता / अिभभावक यवसाय (Mother / माता / अिभभावक योयता (Mother
Others OTHERS
Guardian Occupation) / Guardian Qualification)
परीा राय-पहला िवकप (Exam परीा शहर-पहला िवकप (Exam
RAJASTHAN AJMER
State 1st Choice ) City 1st Choice )
परीा राय-दूसरा िवकप (Exam परीा शहर-दूसरा िवकप (Exam
RAJASTHAN JAIPUR
State 2nd Choice ) City 2nd Choice )
परीा राय-तीसरा िवकप (Exam परीा शहर-तीसरा िवकप (Exam
RAJASTHAN SIKAR
State 3rd Choice ) City 3rd Choice )
परीा राय-चौथा िवकप (Exam परीा शहर-चौथा िवकप (Exam
RAJASTHAN JODHPUR
State 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 Urban
Schooling)
कू ल / कॉलेज का कार (Type of योयता परीा राय (Qualifying
Private Unaided RAJASTHAN
School / College) Examination State)
योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY
Ajmer कू ल बोड (School Board)
Examination District) EDUCATION
का 10वीं की माकशीट/माणप के
अनुसार िवालय/कॉलेज का नाम
Army public school कू ल / कॉलेज का पता (School /
(School/College name should be as army public school nasirabad distt ajmer raj
nasirabad distt ajmer raj College Address)
per Class 10th Mark
sheet/certificate)
रोल नंबर 10वीं माणप के अनुसार
कू ल / कॉलेज िपनकोड (School /
14010 (Roll number as per 10th 11138842
College Pincode)
certificate)
पिरणाम मोड (Result Mode) Percentage पूणा क (Total Marks) 392.0
ातांक (Obtain Marks) 392.0 ितशत (Percentage) 100.00
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) Board of Secondary Urban
Schooling)
Education, 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 RAJASTHAN
School / College) Examination State)
योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY
Ajmer कू ल बोड (School Board)
Examination District) EDUCATION
का 12वीं की माकशीट/माणप के
अनुसार िवालय/कॉलेज का नाम
army public school कू ल / कॉलेज का पता (School / ARMY PUBLIC SCHOOL NASIRABAD DISTT
(School/College name should be as
nasirabad distt ajmer raj College Address) AJMER RAJ
per Class 12th Mark
sheet/certificate)
रोल नंबर 12वीं माणप के अनुसार
कू ल / कॉलेज िपनकोड (School /
14010 (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 (Are you a Twin and both applying for JEE (MAIN) – NO
2024)?
आपातकालीन संपक िववरण प (Emergency Contact Details)
दे श (Country) INDIA दे श कोड (Country Code) +91
मोबाइल नंबर (Mobile Number) 9501005210 ईमेल आईडी (Email ID) rahulsinghrawat010@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) CPADHMZYK8
लेन-दे न की ितिथ (Date of
परीा शु क (Exam Fee) 900.0 30-11-2023 18:22:05 PM
Transaction)
शु क जमा िकया गया (Fee Submitted
30-11-2023 18:21:53 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 : 157.38.241.40 Date of Downloading : 16-01-2024 21:33:59 PM