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. यितगत योरा (Contact Details) वतमान पता (Present Address) 20, DELHI POLICE पता (Premises No/ Name) ईमेल पता (Email Address) NITINYADAV.500000@GMAIL.COM QUARTERS उप-थानीयता (Sub- NEAR ITL PUBLIC SCHOOL DWARKA थानीयता (Locality) DWARKA SEC.-9 Locality)(Optional) SEC.-9 दे श कोड (Country Code) 91 दे श (Country) INDIA राय (State) DELHI िजला (District) New Delhi वै किपक संपक सू (Alternate मोबाइल नंबर (Mobile Number) 91 - 9530226889 9352025969 Contact No.) (Optional) िपन कोड (Pin Code) 110077 थायी पता (Permanent Address) VILL.- AMARSAR , पता (Premises No/ Name) थानीयता (Locality) DIST.- JHUNJHUNU TEH.- BUHANA उप-थानीयता (Sub- NA दे श (Country) INDIA Locality)(Optional): राय (State) RAJASTHAN िजला (District) Jhunjhunu िपन कोड (Pin Code) 333502 यितगत योरा (PERSONAL DETAILS) अयथी की जम ितिथ (Candidate's अयथी का नाम (Candidate's Name) NITIN 23-07-2006 Date of Birth) िपता / अिभभावक का नाम (Father / माता / अिभभावक का नाम (Mother / MOHAN LAL SAROJ DEVI Guardian Name) Guardian Name) िलंग (Gender) MALE राटीयता (Nationality ) INDIAN पहचान संया (Identification पहचान के कार (Identity Type) PAN CARD COXPN7941C Number) राय / केद शािसत दे श जहाँ से 12वीं / समक उीण / उपिथत (State/ UT RAJASTHAN े 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 Residence NO URBAN Diabetic ? ) ) यिद आप एक Pwd उमीदवार ह , तो या आपके पास ब चमाक िवकलांगता है (If you वािषक पािरवािरक आय ( Annual NA 800000 AND ABOVE are a Pwd Candidate, do you have Family Income ) benchmark disability)? योयता परीा म कू ली िशा का तैयारी का तरीका ( Mode of Preparation Correspondence Courses मायम ( Medium of schooling in English ) qualifying exam ) परीा कद िववरण (Exam centre Details) परीा 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 / GOVERNMENT िपता / अिभभावक योयता (Father / Graduate Guardian Occupation) SERVICE Guardian Qualification) माता / अिभभावक यवसाय (Mother / माता / अिभभावक योयता (Mother / Others OTHERS Guardian Occupation) Guardian Qualification) परीा राय-पहला िवकप (Exam State परीा शहर-पहला िवकप (Exam DELHI DELHI/NEW DELHI 1st Choice ) City 1st Choice ) परीा राय-दूसरा िवकप (Exam State परीा शहर-दूसरा िवकप (Exam City UTTAR PRADESH NOIDA/GREATER NOIDA 2nd Choice ) 2nd Choice ) परीा राय-तीसरा िवकप (Exam State परीा शहर-तीसरा िवकप (Exam UTTAR PRADESH GHAZIABAD 3rd Choice ) City 3rd Choice ) परीा राय-चौथा िवकप (Exam State परीा शहर-चौथा िवकप (Exam City RAJASTHAN JAIPUR 4th Choice ) 4th Choice ) न प मायम (Question Paper Medium) English 10वीं या समक योयता िववरण (10th or equivalent Qualification Details) उीण / सिमिलत होने का वष (Year उीण की िथित (Pass Status) Passed 2022 of Passing/Appearing) कू िलंग का थान (Place of योयता परीा (Qualifying Exam) 10 th or equivalent Urban Schooling) कू ल / कॉलेज का कार (Type of School योयता परीा राय (Qualifying Private Unaided RAJASTHAN / College) Examination State) योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY Jaipur कू ल बोड (School Board) Examination District) EDUCATION का 10वीं की माकशीट/माणप के अनुसार िवालय/कॉलेज का नाम vadanta int school kalwad कू ल / कॉलेज का पता (School / Behind Kardhni Hatoj, Kalwar Rd, Jaipur, (School/College name should be as road jaipur raj College Address) Rajasthan 302016 per Class 10th Mark sheet/certificate) रोल नंबर 10वीं माणप के अनुसार कू ल / कॉलेज िपनकोड (School / College 302016 (Roll number as per 10th 11178093 Pincode) certificate) पिरणाम मोड (Result Mode) Percentage पूणा क (Total Marks) 500.0 ातांक (Obtain Marks) 399.0 ितशत (Percentage) 79.80 th 12वीं या समक योयता िववरण (12 or equivalent Qualification Details) उीण / सिमिलत होने का वष (Year उीण की िथित (Pass Status) Appearing 2024 of Passing/Appearing) The final examination of the 10+2 system, conducted by any recognized Central/ State Board, such as the Central कू िलंग का थान (Place of योयता परीा (Qualifying Exam) Board of Secondary Rural Schooling) Education, New Delhi; Council for the Indian School Certificate Examinations, New Delhi etc. कू ल / कॉलेज का कार (Type of School योयता परीा राय (Qualifying Private Unaided RAJASTHAN / College) Examination State) योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY Jhunjhunu कू ल बोड (School Board) Examination District) EDUCATION का 12वीं की माकशीट/माणप के अनुसार िवालय/कॉलेज का नाम Rao Gheesa Ram Shiksha कू ल / कॉलेज का पता (School / Singhana, Buhana Bypass Rd, near Bhora Wala (School/College name should be as Niketan College Address) Kuaa, Simani, Prithvipura, Rajasthan 333502 per Class 12th Mark sheet/certificate) रोल नंबर 12वीं माणप के अनुसार कू ल / कॉलेज िपनकोड (School / College 333502 (Roll number as per 12th NA Pincode) certificate) अितिरत जानकािरयां (Additional Details) या आप जु ड़वा ह और दोनों जे ईई (मे न) - 2024 के िलए आवे दन कर रहे NO ह (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) 7627017419 ईमेल आईडी (Email ID) phase2028@gmail.com उमीदवार ा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) CPADGSLWT8 लेन-दे न की ितिथ (Date of परीा शु क (Exam Fee) 1800.0 01-01-1900 00:00:00 AM Transaction) शु क जमा िकया गया (Fee Submitted 20-11-2023 21:10:11 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 : 49.36.181.137 Date of Downloading : 09-02-2024 18:52:21 PM