सं युत वे श परीा (मु य)

Joint Entrance Examination (Main)

JEE(Main)

APPLICATION NUMBER 240310094410

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)
R.N. MUKHERJEE ROAD
पता (Premises No/ Name) ,P.O-BASIRHAT R/S, ईमेल पता (Email Address) NATHBABLU383@GMAIL.COM
JIRAKPUR
उप-थानीयता (Sub-
थानीयता (Locality) BHABLA RAIL GATE BHABLA
Locality)(Optional)
दे श कोड (Country Code) 91 दे श (Country) INDIA
राय (State) WEST BENGAL िजला (District) 24 Paraganas North
वै किपक संपक सू (Alternate Contact
मोबाइल नंबर (Mobile Number) 91 - 9749146009 NA
No.) (Optional)
िपन कोड (Pin Code) 743412
थायी पता (Permanent Address)
R.N. MUKHERJEE ROAD
पता (Premises No/ Name) ,P.O-BASIRHAT R/S, थानीयता (Locality) BHABLA RAIL GATE
JIRAKPUR
उप-थानीयता (Sub-
BHABLA दे श (Country) INDIA
Locality)(Optional):
राय (State) WEST BENGAL िजला (District) 24 Paraganas North
िपन कोड (Pin Code) 743412
यितगत योरा (PERSONAL DETAILS)
अयथी की जम ितिथ (Candidate's
अयथी का नाम (Candidate's Name) KANCHAN NATH 23-10-2005
Date of Birth)
िपता / अिभभावक का नाम (Father / माता / अिभभावक का नाम (Mother /
BABLU NATH JAYANTI NATH
Guardian Name) Guardian Name)
िलंग (Gender) MALE राटीयता (Nationality ) INDIAN
ANY OTHER VALID
पहचान के कार (Identity Type) GOVT IDENTITY WITH पहचान संया (Identification Number) 832746267418
PHOTOGRAPH
राय / केद शािसत दे श जहाँ से 12वीं /
समक उीण / उपिथत (State/ UT
WEST BENGAL े णी (Category ) OBC-(NCL) AS PER CENTRAL LIST
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 0-100000
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
Online Coaching मायम ( Medium of schooling in Bengali
)
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 GRADUATE
Guardian Occupation) Guardian Qualification)
परीा राय-पहला िवकप (Exam State परीा शहर-पहला िवकप (Exam City
WEST BENGAL KOLKATA
1st Choice ) 1st Choice )
परीा राय-दूसरा िवकप (Exam State परीा शहर-दूसरा िवकप (Exam City
nd WEST BENGAL nd HOWRAH
2 Choice ) 2 Choice )
परीा राय-तीसरा िवकप (Exam State परीा शहर-तीसरा िवकप (Exam City
WEST BENGAL HOOGHLY
3rd Choice ) 3rd Choice )
परीा राय-चौथा िवकप (Exam State परीा शहर-चौथा िवकप (Exam City
WEST BENGAL KALYANI
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 WEST BENGAL
College) Examination State)
योयता परीा िजला (Qualifying WEST BENGAL BOARD OF
24 Paraganas North कू ल बोड (School Board)
Examination District) SECONDARY EDUCATION
का 10वीं की माकशीट/माणप के
अनुसार िवालय/कॉलेज का नाम BASIRHAT TOWN HIGH कू ल / कॉलेज का पता (School / College
BASIRHAT, NORTH 24 PARGANAS
(School/College name should be as per SCHOOL Address)
Class 10th Mark sheet/certificate)
कू ल / कॉलेज िपनकोड (School / College रोल नंबर 10वीं माणप के अनुसार (Roll
743411 706251N0092
Pincode) number as per 10th certificate)
पिरणाम मोड (Result Mode) Percentage पूणा क (Total Marks) 700.0
ातांक (Obtain Marks) 623.0 ितशत (Percentage) 89.00
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)
Any Public School/ Board/
University examination in
India or any foreign country
योयता परीा (Qualifying Exam) is recognized as equivalent कू िलंग का थान (Place of Schooling) Urban
to the 10+2 system by the
Association of Indian
Universities (AIU).
कू ल / कॉलेज का कार (Type of School / योयता परीा राय (Qualifying
Government Aided Private WEST BENGAL
College) Examination State)
योयता परीा िजला (Qualifying WEST BENGAL COUNCIL OF HIGHER
24 Paraganas North कू ल बोड (School Board)
Examination District) SECONDARY EDUCATION
का 12वीं की माकशीट/माणप के
अनुसार िवालय/कॉलेज का नाम BASIRHAT TOWN HIGH कू ल / कॉलेज का पता (School / College
BASIRHAT, NORTH 24 PARGANAS
(School/College name should be as per SCHOOL Address)
Class 12th Mark sheet/certificate)
कू ल / कॉलेज िपनकोड (School / College रोल नंबर 12वीं माणप के अनुसार (Roll
743411 NA
Pincode) 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) 8159832942 ईमेल आईडी (Email ID) nathkn9339@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) CPADFTRLB1
परीा शु क (Exam Fee) 900.0 लेन-दे न की ितिथ (Date of Transaction) 01-01-1900 00:00:00 AM
शु क जमा िकया गया (Fee Submitted
06-11-2023 13:42:50 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 : 103.77.138.148 Date of Downloading : 06-11-2023 13:44:45 PM