सं युत वे श परीा (मु य)

Joint Entrance Examination (Main)

JEE(Main)
APPLICATION
240311290902
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)
पता (Premises No/ Name) MISHRAWALIYA ईमेल पता (Email Address) SATYENDRAMISHRA0123@GMAIL.COM
उप-थानीयता (Sub-
थानीयता (Locality) MISHRAWALIYA,JALALPUR,SARAN NA
Locality)(Optional)
दे श कोड (Country Code) 91 दे श (Country) INDIA
राय (State) BIHAR िजला (District) Saran
वै किपक संपक सू
मोबाइल नंबर (Mobile
91 - 6202715197 (Alternate Contact 7250158321
Number)
No.) (Optional)
िपन कोड (Pin Code) 841412
थायी पता (Permanent Address)
पता (Premises No/ Name) MISHRAWALIYA थानीयता (Locality) MISHRAWALIYA,JALALPUR,SARAN
उप-थानीयता (Sub-
NA दे श (Country) INDIA
Locality)(Optional):
राय (State) BIHAR िजला (District) Saran
िपन कोड (Pin Code) 841412
यितगत योरा (PERSONAL DETAILS)
अयथी का नाम (Candidate's अयथी की जम ितिथ
NIRBHAY KUMAR MISHRA 27-02-2006
Name) (Candidate's Date of Birth)
िपता / अिभभावक का नाम माता / अिभभावक का नाम
SATYENDRA MISHRA NAINA MISHRA
(Father / Guardian Name) (Mother / Guardian Name)
िलंग (Gender) MALE राटीयता (Nationality ) INDIAN
पहचान के कार (Identity BANK PASSBOOK WITH पहचान संया (Identification
397329212471
Type) PHOTOGRAPH Number)
राय / केद शािसत दे श जहाँ
से 12वीं / समक उीण /
उपिथत (State/ UT from BIHAR े णी (Category ) GEN-EWS
where 12th/ Equivalent
Passed/ Appearing)
या आपको मधुमेह ह  (Are िनवास की जगह ( Place of
NO RURAL
You Diabetic ? ) Residence )
यिद आप एक Pwd उमीदवार ह ,
तो या आपके पास ब चमाक
वािषक पािरवािरक आय (
िवकलांगता है (If you are a NA 100001-200000
Annual Family Income )
Pwd Candidate, do you have
benchmark disability)?
योयता परीा म कू ली िशा
तैयारी का तरीका ( Mode of का मायम ( Medium of
Tutorial Classes in School English
Preparation ) schooling in qualifying
exam )
परीा कद िववरण (Exam centre Details)
परीा के स के िलए आवे दन
के िलए आवे दन (Apply For) B.E./B.Tech कर (Session Of Exam Apply Session 1 & Session 2
For)
िपता / अिभभावक यवसाय िपता / अिभभावक योयता
(Father / Guardian AGRICULTURE (Father / Guardian Matriculate
Occupation) Qualification)
माता / अिभभावक यवसाय माता / अिभभावक योयता
(Mother / Guardian Agriculture (Mother / Guardian ILLITERATE
Occupation) Qualification)
परीा राय-पहला िवकप परीा शहर-पहला िवकप
BIHAR PATNA
(Exam State 1st Choice ) (Exam City 1st Choice )
परीा राय-दूसरा िवकप परीा शहर-दूसरा िवकप
BIHAR GAYA
(Exam State 2nd Choice ) (Exam City 2nd Choice )
परीा राय-तीसरा िवकप परीा शहर-तीसरा िवकप
BIHAR PURNEA
(Exam State 3rd Choice ) (Exam City 3rd Choice )
परीा राय-चौथा िवकप परीा शहर-चौथा िवकप
BIHAR DARBHANGA
(Exam State 4th Choice ) (Exam 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 (Year of 2022
Passing/Appearing)
योयता परीा (Qualifying कू िलंग का थान (Place of
10 th or equivalent Rural
Exam) Schooling)
योयता परीा राय
कू ल / कॉलेज का कार (Type
Private Unaided (Qualifying Examination BIHAR
of School / College)
State)
योयता परीा िजला
CENTRAL BOARD OF SECONDARY
(Qualifying Examination Saran कू ल बोड (School Board)
EDUCATION
District)
का 10वीं की
माकशीट/माणप के अनुसार
िवालय/कॉलेज का नाम कू ल / कॉलेज का पता (School
galaxy residential public school jalalpur chapra,saran,br
(School/College name should / College Address)
be as per Class 10th Mark
sheet/certificate)
रोल नंबर 10वीं माणप के
कू ल / कॉलेज िपनकोड (School
841412 अनुसार (Roll number as per 22243866
/ College Pincode)
10th certificate)
पिरणाम मोड (Result Mode) Percentage पूणा क (Total Marks) 500.0
ातांक (Obtain Marks) 458.0 ितशत (Percentage) 91.60
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 (Year of 2024
Passing/Appearing)
Any Public School/ Board/ University
examination in India or any foreign country
योयता परीा (Qualifying कू िलंग का थान (Place of
is recognized as equivalent to the 10+2 Urban
Exam) Schooling)
system by the Association of Indian
Universities (AIU).
योयता परीा राय
कू ल / कॉलेज का कार (Type
Private Unaided (Qualifying Examination BIHAR
of School / College)
State)
योयता परीा िजला
CENTRAL BOARD OF SECONDARY
(Qualifying Examination Saran कू ल बोड (School Board)
EDUCATION
District)
का 12वीं की
माकशीट/माणप के अनुसार
िवालय/कॉलेज का नाम कू ल / कॉलेज का पता (School
rnp public school rajendra sarobar, kashi bajar chapra
(School/College name should / College Address)
be as per Class 12th Mark
sheet/certificate)
रोल नंबर 12वीं माणप के
कू ल / कॉलेज िपनकोड (School
841301 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
NO
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
9504473921 ईमेल आईडी (Email ID) satyendramishra00948@gmail.com
Number)
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 CPADHMUXH1
Mode) ID)
लेन-दे न की ितिथ (Date of
परीा शु क (Exam Fee) 1800.0 01-01-1900 00:00:00 AM
Transaction)
शु क जमा िकया गया (Fee
30-11-2023 17:19:55 PM
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 : 157.35.53.139 Date of Downloading : 06-12-2023 10:13:51 AM