सं युत वे श परीा (मु य)

Joint Entrance Examination (Main)

JEE(Main)

APPLICATION NUMBER 240311259608

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)
SAIDAPUR
पता (Premises No/ Name) ईमेल पता (Email Address) ANUBHAVSHARMA7905@GMAIL.COM
CHHIVALAHA
उप-थानीयता (Sub-
थानीयता (Locality) RAE BARELI LALGANJ
Locality)(Optional)
दे श कोड (Country Code) +91 दे श (Country) INDIA
राय (State) UTTAR PRADESH िजला (District) Rae Bareli
वै किपक संपक सू (Alternate
मोबाइल नंबर (Mobile Number) +91 - 9451831601 NA
Contact No.) (Optional)
िपन कोड (Pin Code) 229216
थायी पता (Permanent Address)
SAIDAPUR
पता (Premises No/ Name) थानीयता (Locality) RAE BARELI
CHHIVALAHA
उप-थानीयता (Sub-
LALGANJ दे श (Country) INDIA
Locality)(Optional):
राय (State) UTTAR PRADESH िजला (District) Rae Bareli
िपन कोड (Pin Code) 229216
यितगत योरा (PERSONAL DETAILS)
अयथी की जम ितिथ (Candidate's
अयथी का नाम (Candidate's Name) ADITYA SHARMA 09-10-2006
Date of Birth)
िपता / अिभभावक का नाम (Father / माता / अिभभावक का नाम (Mother /
SUNIL SHARMA SANNO SHARMA
Guardian Name) 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 937160062225
Number)
PHOTOGRAPH
राय / केद शािसत दे श जहाँ से 12वीं /
समक उीण / उपिथत (State/ UT
UTTAR PRADESH े णी (Category ) OBC-(NCL) AS PER CENTRAL LIST
from where 12th/ Equivalent Passed/
Appearing)
या आपको मधुमेह ह  (Are You िनवास की जगह ( Place of
NO RURAL
Diabetic ? ) Residence )
यिद आप एक Pwd उमीदवार ह , तो या
आपके पास ब चमाक िवकलांगता है (If वािषक पािरवािरक आय ( Annual
NA 0-100000
you are a Pwd Candidate, do you Family Income )
have benchmark disability)?
योयता परीा म कू ली िशा का
तैयारी का तरीका ( Mode of
Online Coaching मायम ( Medium of schooling in English
Preparation )
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 /
PRIVATE SERVICE Matriculate
Guardian Occupation) Guardian Qualification)
माता / अिभभावक यवसाय (Mother / माता / अिभभावक योयता (Mother /
Others ILLITERATE
Guardian Occupation) Guardian Qualification)
परीा राय-पहला िवकप (Exam परीा शहर-पहला िवकप (Exam
UTTAR PRADESH KANPUR
State 1st Choice ) City 1st Choice )
परीा राय-दूसरा िवकप (Exam State परीा शहर-दूसरा िवकप (Exam
UTTAR PRADESH LUCKNOW
2nd Choice ) City 2nd Choice )
परीा राय-तीसरा िवकप (Exam परीा शहर-तीसरा िवकप (Exam
UTTAR PRADESH PRATAPGARH
State 3rd Choice ) City 3rd Choice )
परीा राय-चौथा िवकप (Exam State परीा शहर-चौथा िवकप (Exam
UTTAR PRADESH ALLAHABAD/PRAYAGRAJ
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 (Year
उीण की िथित (Pass Status) Passed 2021
of Passing/Appearing)
कू िलंग का थान (Place of
योयता परीा (Qualifying Exam) 10 th or equivalent Urban
Schooling)
कू ल / कॉलेज का कार (Type of योयता परीा राय (Qualifying
Private Unaided UTTAR PRADESH
School / College) Examination State)
योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY
Rae Bareli कू ल बोड (School Board)
Examination District) EDUCATION
का 10वीं की माकशीट/माणप के
अनुसार िवालय/कॉलेज का नाम
bakshi memo public कू ल / कॉलेज का पता (School / 71149- BAKSHI MEMO PUBLIC SCHOOL
(School/College name should be as
school lalganj rae bareli College Address) LALGANJ RAE BARELI
per Class 10th Mark
sheet/certificate)
रोल नंबर 10वीं माणप के अनुसार
कू ल / कॉलेज िपनकोड (School /
229206 (Roll number as per 10th 23263903
College Pincode)
certificate)
पिरणाम मोड (Result Mode) Percentage पूणा क (Total Marks) 500.0
ातांक (Obtain Marks) 453.0 ितशत (Percentage) 90.60
th
12वीं या समक योयता िववरण (12 or equivalent Qualification Details)
उीण / सिमिलत होने का वष (Year
उीण की िथित (Pass Status) Passed 2023
of Passing/Appearing)
Senior Secondary School
Examination conducted
कू िलंग का थान (Place of
योयता परीा (Qualifying Exam) by the National Institute Urban
Schooling)
of Open Schooling with a
minimum of five subjects.
कू ल / कॉलेज का कार (Type of योयता परीा राय (Qualifying
Private Unaided UTTAR PRADESH
School / College) Examination State)
योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY
Rae Bareli कू ल बोड (School Board)
Examination District) EDUCATION
का 12वीं की माकशीट/माणप के
अनुसार िवालय/कॉलेज का नाम BAKSHI MEMO
कू ल / कॉलेज का पता (School / 71149 BAKSHI MEMO PUBLIC SCHOOL
(School/College name should be as PUBLIC SCHOOL
College Address) LALGANJ RAE BARELI
per Class 12th Mark LALGANJ RAE BARELI
sheet/certificate)
रोल नंबर 12वीं माणप के अनुसार
कू ल / कॉलेज िपनकोड (School /
229206 (Roll number as per 12th 23742443
College Pincode)
certificate)
पिरणाम मोड (Result Mode) Percentage पूणा क (Total Marks) 500.0
ातांक (Obtain Marks) 443.0 ितशत (Percentage) 88.60
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 a Twin and both applying for JEE (MAIN) – NO
2024)?
आपातकालीन संपक िववरण प (Emergency Contact Details)
दे श (Country) INDIA दे श कोड (Country Code) +91
मोबाइल नंबर (Mobile Number) 7905432084 ईमेल आईडी (Email ID) adityas9451@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) 249905466
 लेन-दे न की ितिथ (Date of
परीा शु क (Exam Fee) 900.0 28-02-2024 19:53:56 PM
Transaction)
शु क जमा िकया गया (Fee Submitted
28-02-2024 19:53:14 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 : 49.43.119.59 Date of Downloading : 28-02-2024 19:54:45 PM