सं युत वे श परीा (मु य)

Joint Entrance Examination (Main)

JEE(Main)

APPLICATION NUMBER 240310995280

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)
FLAT 401 B WING
पता (Premises No/ Name) ईमेल पता (Email Address) KAPILP2297@GMAIL.COM
DWARKA RECIDENCY
थानीयता (Locality) KASBA BAWDA उप-थानीयता (Sub-Locality)(Optional) NA
दे श कोड (Country Code) 91 दे श (Country) INDIA
राय (State) MAHARASHTRA िजला (District) Kolhapur
वै किपक संपक सू (Alternate Contact
मोबाइल नंबर (Mobile Number) 91 - 8149092297 NA
No.) (Optional)
िपन कोड (Pin Code) 416006
थायी पता (Permanent Address)
FLAT 401 B WING
पता (Premises No/ Name) थानीयता (Locality) KASBA BAWDA
DWARKA RECIDENCY
उप-थानीयता (Sub-
NA दे श (Country) INDIA
Locality)(Optional):
राय (State) MAHARASHTRA िजला (District) Kolhapur
िपन कोड (Pin Code) 416006
यितगत योरा (PERSONAL DETAILS)
KAPIL SACHIN अयथी की जम ितिथ (Candidate's Date
अयथी का नाम (Candidate's Name) 13-11-2006
PORLEKAR of Birth)
िपता / अिभभावक का नाम (Father / माता / अिभभावक का नाम (Mother /
SACHIN SHEETAL
Guardian Name) Guardian Name)
िलंग (Gender) MALE राटीयता (Nationality ) INDIAN
ANY OTHER VALID
पहचान के कार (Identity Type) GOVT IDENTITY WITH पहचान संया (Identification Number) 510357239349
PHOTOGRAPH
राय / केद शािसत दे श जहाँ से 12वीं /
समक उीण / उपिथत (State/ UT
MAHARASHTRA े 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 Family
NA 800000 AND ABOVE
are a Pwd Candidate, do you have Income )
benchmark disability)?
योयता परीा म कू ली िशा का मायम (
तैयारी का तरीका ( Mode of Preparation
Self-Study Medium of schooling in qualifying English
)
exam )
परीा कद िववरण (Exam centre Details)
परीा के स के िलए आवे दन कर (Session
के िलए आवे दन (Apply For) B.E./B.Tech Session 1 & Session 2
Of Exam Apply For)
िपता / अिभभावक यवसाय (Father / िपता / अिभभावक योयता (Father /
BUSINESS Graduate
Guardian Occupation) 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 1st
MAHARASHTRA KOLHAPUR
1st Choice ) Choice )
परीा राय-दूसरा िवकप (Exam State परीा शहर-दूसरा िवकप (Exam City 2nd
MAHARASHTRA SANGLI
2nd Choice ) Choice )
परीा राय-तीसरा िवकप (Exam State परीा शहर-तीसरा िवकप (Exam City 3rd
MAHARASHTRA SATARA
3rd Choice ) Choice )
परीा राय-चौथा िवकप (Exam State परीा शहर-चौथा िवकप (Exam City 4th
MAHARASHTRA PUNE
4th Choice ) 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 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 MAHARASHTRA
College) Examination State)
योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY
Kolhapur कू ल बोड (School Board)
Examination District) EDUCATION
का 10वीं की माकशीट/माणप के
अनुसार िवालय/कॉलेज का नाम shanitiniketan school and jr कू ल / कॉलेज का पता (School / College
morewadi rk nagar kolhapur
(School/College name should be as per college Address)
Class 10th Mark sheet/certificate)
कू ल / कॉलेज िपनकोड (School / College रोल नंबर 10वीं माणप के अनुसार (Roll
416013 15125463
Pincode) number as per 10th certificate)
पिरणाम मोड (Result Mode) Percentage पूणा क (Total Marks) 500.0
ातांक (Obtain Marks) 467.0 ितशत (Percentage) 93.40
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 MAHARASHTRA
College) Examination State)
MAHARASHTRA STATE BOARD OF
योयता परीा िजला (Qualifying
Kolhapur कू ल बोड (School Board) SEC. & HR. SECONDARY
Examination District)
EDUCATION
का 12वीं की माकशीट/माणप के
अनुसार िवालय/कॉलेज का नाम कू ल / कॉलेज का पता (School / College
csv jr college new palace kolhapur
(School/College name should be as per Address)
Class 12th Mark sheet/certificate)
कू ल / कॉलेज िपनकोड (School / College रोल नंबर 12वीं माणप के अनुसार (Roll
416003 NA
Pincode) 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) 9890153244 ईमेल आईडी (Email ID) sachinporlekar77@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)
परीा शु क (Exam Fee)
शु क जमा िकया गया (Fee Submitted
On)
Online लेन-दे न आईडी (Transaction ID) ZIC51738302840
1000.0 लेन-दे न की ितिथ (Date of Transaction) 09-02-2024 15:00:10 PM
09-02-2024 14:58:06 PM
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 : 223.233.80.45 Date of Downloading : 28-03-2024 12:15:55 PM