सं युत वे श परीा (मु य)

Joint Entrance Examination (Main)

JEE(Main)
APPLICATION
240310457497
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)
30E,ABDUL SARDAR STREET,KARGIL
पता (Premises No/ Name) ईमेल पता (Email Address) VIMALAVEL.VM@GMAIL.COM
NAGAR,TIRUVOTTIYUR,CHENNAI-19
उप-थानीयता (Sub-
थानीयता (Locality) THIRUVOTTRIYUR NA
Locality)(Optional)
दे श कोड (Country Code) 91 दे श (Country) INDIA
राय (State) TAMILNADU िजला (District) Chennai
वै किपक संपक सू (Alternate
मोबाइल नंबर (Mobile Number) 91 - 7299969939 7200098818
Contact No.) (Optional)
िपन कोड (Pin Code) 600019
थायी पता (Permanent Address)
30E,ABDUL SARDAR STREET,KARGIL
पता (Premises No/ Name) थानीयता (Locality) THIRUVOTTRIYUR
NAGAR,TIRUVOTTIYUR,CHENNAI-19
उप-थानीयता (Sub-
NA दे श (Country) INDIA
Locality)(Optional):
राय (State) TAMILNADU िजला (District) Chennai
िपन कोड (Pin Code) 600019
यितगत योरा (PERSONAL DETAILS)
अयथी का नाम (Candidate's अयथी की जम ितिथ
VIMALAVEL V M 19-06-2007
Name) (Candidate's Date of Birth)
िपता / अिभभावक का नाम माता / अिभभावक का नाम
MADHANAGOPAL V VIJAYALAKSHMI M
(Father / Guardian Name) (Mother / Guardian Name)
िलंग (Gender) MALE राटीयता (Nationality ) INDIAN
ANY OTHER VALID GOVT IDENTITY पहचान संया (Identification
पहचान के कार (Identity Type) 521150585116
WITH PHOTOGRAPH Number)
राय / केद शािसत दे श जहाँ से
12वीं / समक उीण / उपिथत
TAMILNADU े णी (Category ) OBC-(NCL) AS PER CENTRAL LIST
(State/ UT 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
वािषक पािरवािरक आय ( Annual
िवकलांगता है (If you are a Pwd NA 100001-200000
Family Income )
Candidate, do you have
benchmark disability)?
योयता परीा म कू ली िशा का
तैयारी का तरीका ( Mode of
Self-Study मायम ( Medium of schooling English
Preparation )
in 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 िपता / अिभभावक योयता
(Father / Guardian BUSINESS (Father / Guardian Post Graduate
Occupation) Qualification)
माता / अिभभावक यवसाय माता / अिभभावक योयता
(Mother / Guardian Business (Mother / Guardian MATRICULATE
Occupation) Qualification)
परीा राय-पहला िवकप परीा शहर-पहला िवकप (Exam
TAMILNADU CHENNAI
(Exam State 1st Choice ) City 1st Choice )
परीा राय-दूसरा िवकप (Exam परीा शहर-दूसरा िवकप (Exam
TAMILNADU TIRUCHIRAPPALLI
State 2nd Choice ) City 2nd Choice )
परीा राय-तीसरा िवकप परीा शहर-तीसरा िवकप
TAMILNADU THANJAVUR
(Exam State 3rd Choice ) (Exam City 3rd Choice )
परीा राय-चौथा िवकप परीा शहर-चौथा िवकप (Exam
TAMILNADU MADURAI
(Exam 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
उीण की िथित (Pass Status) Passed 2022
(Year of Passing/Appearing)
योयता परीा (Qualifying कू िलंग का थान (Place of
10 th or equivalent Urban
Exam) Schooling)
योयता परीा राय
कू ल / कॉलेज का कार (Type of
Private Unaided (Qualifying Examination TAMILNADU
School / College)
State)
योयता परीा िजला
CENTRAL BOARD OF SECONDARY
(Qualifying Examination Chennai कू ल बोड (School Board)
EDUCATION
District)
का 10वीं की माकशीट/माणप
के अनुसार िवालय/कॉलेज का
कू ल / कॉलेज का पता (School / 9,ellai amman koil street,thiruvottiyur
नाम (School/College name s r d khemka v vidyalaya thiruvottiyur chennai
College Address) chennai-600 019
should be as per Class 10th
Mark sheet/certificate)
रोल नंबर 10वीं माणप के
कू ल / कॉलेज िपनकोड (School /
600019 अनुसार (Roll number as per 20197005
College Pincode)
10th certificate)
पिरणाम मोड (Result Mode) Percentage पूणा क (Total Marks) 600.0
ातांक (Obtain Marks) 419.0 ितशत (Percentage) 69.83
th
12वीं या समक योयता िववरण (12 or equivalent Qualification Details)
उीण / सिमिलत होने का वष
उीण की िथित (Pass Status) Appearing 2024
(Year of Passing/Appearing)
योयता परीा (Qualifying Higher Secondary Certificate Vocational कू िलंग का थान (Place of
Urban
Exam) Examination. Schooling)
योयता परीा राय
कू ल / कॉलेज का कार (Type of
Private Unaided (Qualifying Examination TAMILNADU
School / College)
State)
योयता परीा िजला
CENTRAL BOARD OF SECONDARY
(Qualifying Examination Chennai कू ल बोड (School Board)
EDUCATION
District)
का 12वीं की माकशीट/माणप
के अनुसार िवालय/कॉलेज का
कू ल / कॉलेज का पता (School / 11/2,Block no.19,village
नाम (School/College name vimalavel v m
College Address) road,thiruvottiyur,chennai-600019
should be as per Class 12th
Mark sheet/certificate)
रोल नंबर 12वीं माणप के
कू ल / कॉलेज िपनकोड (School /
600019 अनुसार (Roll number as per NA
College Pincode)
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 (Are you
NO
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) 8610440776 ईमेल आईडी (Email ID) babu.mg12@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 लेन-दे न आईडी (Transaction
Online 50764125
Mode) ID)
 लेन-दे न की ितिथ (Date of
परीा शु क (Exam Fee) 900.0 01-03-2024 07:25:43 AM
Transaction)
शु क जमा िकया गया (Fee
01-03-2024 07:25:17 AM
Submitted 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 : 49.204.135.104 Date of Downloading : 01-03-2024 22:48:09 PM