सं युत वे श परीा (मु य)

Joint Entrance Examination (Main)

JEE(Main)

APPLICATION NUMBER 240311218775

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)
VILLAGE -BANKAT POST
OFFI-SISWA P.S-
पता (Premises No/ Name) ईमेल पता (Email Address) PRIYANSHUSHARAN9@GMAIL.COM
BANJARIYA BLOCK-
BANJARIYA
उप-थानीयता (Sub-
थानीयता (Locality) BANKAT SHANTIPURI BELWANWA MOTIHARI
Locality)(Optional)
दे श कोड (Country Code) 91 दे श (Country) INDIA
राय (State) BIHAR िजला (District) Purbi Champaran
वै किपक संपक सू (Alternate
मोबाइल नंबर (Mobile Number) 91 - 9708855223 NA
Contact No.) (Optional)
िपन कोड (Pin Code) 845401
थायी पता (Permanent Address)
VILLAGE -BANKAT POST
OFFI-SISWA P.S-
पता (Premises No/ Name) थानीयता (Locality) BANKAT
BANJARIYA BLOCK-
BANJARIYA
उप-थानीयता (Sub- SHANTIPURI BELWANWA
दे श (Country) INDIA
Locality)(Optional): MOTIHARI
राय (State) BIHAR िजला (District) Purbi Champaran
िपन कोड (Pin Code) 845401
यितगत योरा (PERSONAL DETAILS)
अयथी की जम ितिथ (Candidate's
अयथी का नाम (Candidate's Name) YUVRAJ KUMAR SINGH 18-06-2006
Date of Birth)
िपता / अिभभावक का नाम (Father / माता / अिभभावक का नाम (Mother /
VIJAY KUMAR SINGH BABITA DEVI
Guardian Name) Guardian Name)
िलंग (Gender) MALE राटीयता (Nationality ) INDIAN
ANY OTHER VALID GOVT
पहचान संया (Identification
पहचान के कार (Identity Type) IDENTITY WITH 366106170514
Number)
PHOTOGRAPH
राय / केद शािसत दे श जहाँ से 12वीं /
समक उीण / उपिथत (State/ UT
BIHAR े णी (Category ) GEN-EWS
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 100001-200000
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
Individual Tuition मायम ( Medium of schooling in Hindi
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 /
AGRICULTURE 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 परीा शहर-पहला िवकप (Exam
BIHAR MUZAFFARPUR
State 1st Choice ) City 1st Choice )
परीा राय-दूसरा िवकप (Exam परीा शहर-दूसरा िवकप (Exam
BIHAR PATNA
State 2nd Choice ) City 2nd Choice )
परीा राय-तीसरा िवकप (Exam परीा शहर-तीसरा िवकप (Exam
BIHAR SAMASTIPUR
State 3rd Choice ) City 3rd Choice )
परीा राय-चौथा िवकप (Exam परीा शहर-चौथा िवकप (Exam
BIHAR DARBHANGA
State 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 2022
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
Government School BIHAR
School / College) Examination State)
योयता परीा िजला (Qualifying
Purbi Champaran कू ल बोड (School Board) BIHAR SCHOOL EXAMINATION BOARD
Examination District)
का 10वीं की माकशीट/माणप के
अनुसार िवालय/कॉलेज का नाम
कू ल / कॉलेज का पता (School /
(School/College name should be as Zila school motihari Balua motihari
College Address)
per Class 10th Mark
sheet/certificate)
रोल नंबर 10वीं माणप के अनुसार
कू ल / कॉलेज िपनकोड (School /
845401 (Roll number as per 10th 2200942
College Pincode)
certificate)
पिरणाम मोड (Result Mode) Percentage पूणा क (Total Marks) 500.0
ातांक (Obtain Marks) 418.0 ितशत (Percentage) 83.60
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) Appearing 2024
of Passing/Appearing)
Candidates who have
completed the Class 12 (or
equivalent) examination
outside India or from a Board
not specified above should
कू िलंग का थान (Place of
योयता परीा (Qualifying Exam) produce a certificate from the Urban
Schooling)
Association of Indian
Universities (AIU) to the
effect that the examination
they have passed is equivalent
to the Class 12 Examination
कू ल / कॉलेज का कार (Type of योयता परीा राय (Qualifying
Government School BIHAR
School / College) Examination State)
योयता परीा िजला (Qualifying
Purbi Champaran कू ल बोड (School Board) BIHAR SCHOOL EXAMINATION BOARD
Examination District)
का 12वीं की माकशीट/माणप के
अनुसार िवालय/कॉलेज का नाम
कू ल / कॉलेज का पता (School /
(School/College name should be as LNd college Hospital chowk motihari
College Address)
per Class 12th Mark
sheet/certificate)
रोल नंबर 12वीं माणप के अनुसार
कू ल / कॉलेज िपनकोड (School /
845401 (Roll number as per 12th NA
College Pincode)
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) 9006091847 ईमेल आईडी (Email ID) triptansh22@gmail.com
उमीदवार ारा अपलोड की गई छिवयां (IMAGES UPLOADED BY THE CANDIDATE)

PHOTO
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शु क भु गतान िववरण (Fee Payment Details)

भु गतान का कार (Payment Mode) Online लेन-दे न आईडी (Transaction ID) 90638088675
लेन-दे न की ितिथ (Date of
परीा शु क (Exam Fee) 900.0 24-02-2024 12:25:33 PM
Transaction)
शु क जमा िकया गया (Fee Submitted
24-02-2024 12:24:48 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 : 49.47.134.137 Date of Downloading : 29-02-2024 22:05:00 PM