सं युत वे श परीा (मु य)

Joint Entrance Examination (Main)

JEE(Main)

APPLICATION NUMBER 240310365167

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)
STATE BANK OFFICERS
पता (Premises No/ Name) ईमेल पता (Email Address) ADITYAVAISH739@GMAIL.COM
COLONY
उप-थानीयता (Sub- BEHIND LOVY NURSING HOME, RAHE
थानीयता (Locality) RAMPUR
Locality)(Optional) RAZA ROAD
दे श कोड (Country Code) 91 दे श (Country) INDIA
राय (State) UTTAR PRADESH िजला (District) Rampur
वै किपक संपक सू (Alternate
मोबाइल नंबर (Mobile Number) 91 - 9627302142 8954581199
Contact No.) (Optional)
िपन कोड (Pin Code) 244901
थायी पता (Permanent Address)
STATE BANK OFFICERS
पता (Premises No/ Name) थानीयता (Locality) RAMPUR
COLONY
BEHIND LOVY
उप-थानीयता (Sub-
NURSING HOME, RAHE दे श (Country) INDIA
Locality)(Optional):
RAZA ROAD
राय (State) UTTAR PRADESH िजला (District) Rampur
िपन कोड (Pin Code) 244901
यितगत योरा (PERSONAL DETAILS)
अयथी की जम ितिथ (Candidate's
अयथी का नाम (Candidate's Name) ADITYA VAISH 08-04-2006
Date of Birth)
िपता / अिभभावक का नाम (Father / ADARSH KUMAR माता / अिभभावक का नाम (Mother /
RUCHI VAISH
Guardian Name) VAISH 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 732168723670
Number)
PHOTOGRAPH
राय / केद शािसत दे श जहाँ से 12वीं /
समक उीण / उपिथत (State/ UT
UTTAR PRADESH े 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
Online Coaching 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 1 & Session 2
(Session Of Exam Apply For)
िपता / अिभभावक यवसाय (Father / िपता / अिभभावक योयता (Father /
ENGINEERING Graduate
Guardian Occupation) Guardian Qualification)
माता / अिभभावक यवसाय (Mother / माता / अिभभावक योयता (Mother /
Self-Employment POST GRADUATE
Guardian Occupation) Guardian Qualification)
परीा राय-पहला िवकप (Exam State परीा शहर-पहला िवकप (Exam City
UTTAR PRADESH RAMPUR
1st Choice ) 1st Choice )
परीा राय-दूसरा िवकप (Exam State परीा शहर-दूसरा िवकप (Exam City
UTTAR PRADESH MORADABAD
2nd Choice ) 2nd Choice )
परीा राय-तीसरा िवकप (Exam State परीा शहर-तीसरा िवकप (Exam City
UTTAR PRADESH BAREILLY
3rd Choice ) 3rd Choice )
परीा राय-चौथा िवकप (Exam State परीा शहर-चौथा िवकप (Exam City
UTTAR PRADESH NOIDA/GREATER NOIDA
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
Private Unaided UTTAR PRADESH
/ College) Examination State)
योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY
Rampur कू ल बोड (School Board)
Examination District) EDUCATION
का 10वीं की माकशीट/माणप के
अनुसार िवालय/कॉलेज का नाम WHITEHALL PUBLIC कू ल / कॉलेज का पता (School / WHITEHALL PUBLIC SCHOOL
(School/College name should be as per SCHOOL College Address) RAMPUR - BAREILLY RD RAMPUR UP
Class 10th Mark sheet/certificate)
कू ल / कॉलेज िपनकोड (School / College रोल नंबर 10वीं माणप के अनुसार
81156 25172883
Pincode) (Roll number as per 10th certificate)
पिरणाम मोड (Result Mode) Percentage पूणा क (Total Marks) 500.0
ातांक (Obtain Marks) 456.0 ितशत (Percentage) 91.20
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)
The final examination of
the 10+2 system, conducted
by any recognized Central/
State Board, such as the
Central Board of Secondary
योयता परीा (Qualifying Exam) कू िलंग का थान (Place of Schooling) Urban
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
Private Unaided UTTAR PRADESH
/ College) Examination State)
योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY
Rampur कू ल बोड (School Board)
Examination District) EDUCATION
का 12वीं की माकशीट/माणप के
अनुसार िवालय/कॉलेज का नाम WHITEHALL PUBLIC कू ल / कॉलेज का पता (School / WHITEHALL PUBLIC SCHOOL
(School/College name should be as per SCHOOL College Address) RAMPUR - BAREILLY RD RAMPUR UP
Class 12th Mark sheet/certificate)
कू ल / कॉलेज िपनकोड (School / College रोल नंबर 12वीं माणप के अनुसार
81156 NA
Pincode) (Roll 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) 7248463142 ईमेल आईडी (Email ID) vaishruchi@gmail.com
उमीदवार ारा अपलोड की गई छिवयां (IMAGES UPLOADED BY THE CANDIDATE)

PHOTO

SIGNATURE

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 : 223.233.78.46 Date of Downloading : 06-02-2024 19:45:39 PM