सं युत वे श परीा (मु य)

Joint Entrance Examination (Main)

JEE(Main)

APPLICATION NUMBER 240320207076

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)
पता (Premises No/ Name) AT KENDUPADAR ईमेल पता (Email Address) TUSHARKANTPLB@GMAIL.COM
उप-थानीयता (Sub-
थानीयता (Locality) PHULBANI TOWN NA
Locality)(Optional)
दे श कोड (Country Code) +91 दे श (Country) INDIA
राय (State) ODISHA िजला (District) Kandhamal
वै किपक संपक सू (Alternate
मोबाइल नंबर (Mobile Number) +91 - 9337680869 7008587211
Contact No.) (Optional)
िपन कोड (Pin Code) 762001
थायी पता (Permanent Address)
पता (Premises No/ Name) AT KENDUPADAR थानीयता (Locality) PHULBANI TOWN
उप-थानीयता (Sub-
NA दे श (Country) INDIA
Locality)(Optional):
राय (State) ODISHA िजला (District) Kandhamal
िपन कोड (Pin Code) 762001
यितगत योरा (PERSONAL DETAILS)
TUSHAR KANT अयथी की जम ितिथ (Candidate's
अयथी का नाम (Candidate's Name) 05-07-2003
PRADHAN Date of Birth)
िपता / अिभभावक का नाम (Father / NIHAR RANJAN माता / अिभभावक का नाम (Mother /
BIVAS PRADHAN
Guardian Name) PRADHAN 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 313697304981
Number)
PHOTOGRAPH
राय / केद शािसत दे श जहाँ से 12वीं /
समक उीण / उपिथत (State/ UT
ODISHA े 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 800000 AND ABOVE
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
Self-Study 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 2
(Session Of Exam Apply For)
िपता / अिभभावक यवसाय (Father / TEACHING / िपता / अिभभावक योयता (Father /
Post Graduate
Guardian Occupation) RESEARCH 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
ODISHA BHUBANESWAR
1st Choice ) 1st Choice )
परीा राय-दूसरा िवकप (Exam State परीा शहर-दूसरा िवकप (Exam City
ODISHA PHULBANI (KANDHAMAL)
2nd Choice ) 2nd Choice )
परीा राय-तीसरा िवकप (Exam State परीा शहर-तीसरा िवकप (Exam City
ODISHA SAMBALPUR
3rd Choice ) 3rd Choice )
परीा राय-चौथा िवकप (Exam State परीा शहर-चौथा िवकप (Exam City
ODISHA CUTTACK
4th Choice ) 4th Choice )
न प मायम (Question Paper Medium) English
10वीं या समक योयता िववरण (10th or equivalent Qualification Details)
उीण / सिमिलत होने का वष (Year of
उीण की िथित (Pass Status) Passed 2020
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
Private Unaided ODISHA
College) Examination State)
योयता परीा िजला (Qualifying COUNCIL FOR THE INDIAN SCHOOL
Kandhamal कू ल बोड (School Board)
Examination District) CERTIFICATE EXAMINATIONS
का 10वीं की माकशीट/माणप के
अनुसार िवालय/कॉलेज का नाम CARMEL ENGLISH कू ल / कॉलेज का पता (School / NARAYANI ROAD, PHULBANI, DIST
(School/College name should be as per MEDIUM SCHOOL College Address) KANDHAMAL
Class 10th Mark sheet/certificate)
कू ल / कॉलेज िपनकोड (School / College रोल नंबर 10वीं माणप के अनुसार
762001 7165917
Pincode) (Roll number as per 10th certificate)
पिरणाम मोड (Result Mode) Percentage पूणा क (Total Marks) 600.0
ातांक (Obtain Marks) 562.0 ितशत (Percentage) 93.67
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) Passed 2022
Passing/Appearing)
The final examination of
the 10+2 system,
conducted by any
recognized Central/ State
Board, such as the Central
योयता परीा (Qualifying Exam) Board of Secondary कू िलंग का थान (Place of Schooling) Rural
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
Kendriya vidayalya (KV) ODISHA
College) Examination State)
योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY
Kandhamal कू ल बोड (School Board)
Examination District) EDUCATION
का 12वीं की माकशीट/माणप के
KENDRIYA
अनुसार िवालय/कॉलेज का नाम कू ल / कॉलेज का पता (School / AT MULAGUDARI, PO GUDARI, VIA
VIDYALAYA
(School/College name should be as per College Address) KHAJURIPADA, DIST KANDHAMAL
KANDHAMAL
Class 12th Mark sheet/certificate)
कू ल / कॉलेज िपनकोड (School / College रोल नंबर 12वीं माणप के अनुसार
762012 12640783
Pincode) (Roll number as per 12th certificate)
पिरणाम मोड (Result Mode) Percentage पूणा क (Total Marks) 500.0
ातांक (Obtain Marks) 449.0 ितशत (Percentage) 89.80
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) 7978134232 ईमेल आईडी (Email ID) bibhashpradhan24@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) CPADOOHFK1
 लेन-दे न की ितिथ (Date of
परीा शु क (Exam Fee) 1000.0 28-02-2024 21:27:28 PM
Transaction)
शु क जमा िकया गया (Fee Submitted
28-02-2024 21:21:05 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 : 157.41.248.219 Date of Downloading : 28-02-2024 21:27:28 PM