सं युत वे श परीा (मु य)

Joint Entrance Examination (Main)

JEE(Main)

APPLICATION NUMBER 240310533875

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)
पता (Premises No/ Name) HOUSE NO. 4411 ईमेल पता (Email Address) VARANDEEPVS@GMAIL.COM
STREET 1/12 BHARAT उप-थानीयता (Sub-
थानीयता (Locality) NA
NAGAR Locality)(Optional)
दे श कोड (Country Code) 91 दे श (Country) INDIA
राय (State) HARYANA िजला (District) Sirsa
वै किपक संपक सू (Alternate Contact
मोबाइल नंबर (Mobile Number) 91 - 9671276679 NA
No.) (Optional)
िपन कोड (Pin Code) 125055
थायी पता (Permanent Address)
पता (Premises No/ Name) HOUSE NO. 4411 थानीयता (Locality) STREET 1/12 BHARAT NAGAR
उप-थानीयता (Sub-
NA दे श (Country) INDIA
Locality)(Optional):
राय (State) HARYANA िजला (District) Sirsa
िपन कोड (Pin Code) 125055
यितगत योरा (PERSONAL DETAILS)
अयथी की जम ितिथ (Candidate's
अयथी का नाम (Candidate's Name) PALAKDEEP 15-06-2005
Date of Birth)
िपता / अिभभावक का नाम (Father / माता / अिभभावक का नाम (Mother /
DHARAMJEET SINGH HARVINDER KAUR
Guardian Name) Guardian Name)
िलंग (Gender) MALE राटीयता (Nationality ) INDIAN
CLASS XII ADMIT CARD
पहचान के कार (Identity Type) पहचान संया (Identification Number) 17723897
ISSUED BY THE BOARD
राय / केद शािसत दे श जहाँ से 12वीं /
समक उीण / उपिथत (State/ UT
HARYANA े णी (Category ) OBC-(NCL) AS PER CENTRAL LIST
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 0-100000
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 Of Exam Apply For)
िपता / अिभभावक यवसाय (Father / िपता / अिभभावक योयता (Father /
SELF-EMPLOYMENT Matriculate
Guardian Occupation) Guardian Qualification)
माता / अिभभावक यवसाय (Mother / माता / अिभभावक योयता (Mother /
Not Applicable MATRICULATE
Guardian Occupation) Guardian Qualification)
परीा राय-पहला िवकप (Exam State परीा शहर-पहला िवकप (Exam City
PUNJAB BHATINDA
1st Choice ) 1st Choice )
परीा राय-दूसरा िवकप (Exam State परीा शहर-दूसरा िवकप (Exam City
HARYANA HISAR
2nd Choice ) 2nd Choice )
परीा राय-तीसरा िवकप (Exam State परीा शहर-तीसरा िवकप (Exam City
PUNJAB LUDHIANA
3rd Choice ) 3rd Choice )
परीा राय-चौथा िवकप (Exam State परीा शहर-चौथा िवकप (Exam City
HARYANA AMBALA
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 2021
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 HARYANA
/ College) Examination State)
योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY
Sirsa कू ल बोड (School Board)
Examination District) EDUCATION
का 10वीं की माकशीट/माणप के
अनुसार िवालय/कॉलेज का नाम Shah Satnam ji boys school कू ल / कॉलेज का पता (School /
Sirsa, haryana
(School/College name should be as sirsa College Address)
per Class 10th Mark sheet/certificate)
कू ल / कॉलेज िपनकोड (School / College रोल नंबर 10वीं माणप के अनुसार
125055 17244885
Pincode) (Roll number as per 10th certificate)
पिरणाम मोड (Result Mode) Percentage पूणा क (Total Marks) 500.0
ातांक (Obtain Marks) 462.0 ितशत (Percentage) 92.40
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) Passed 2023
Passing/Appearing)
The final examination of the
10+2 system, conducted by
any recognized Central/ State
Board, such as the Central
योयता परीा (Qualifying Exam) Board of Secondary 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 HARYANA
/ College) Examination State)
योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY
Sirsa कू ल बोड (School Board)
Examination District) EDUCATION
का 12वीं की माकशीट/माणप के
अनुसार िवालय/कॉलेज का नाम Shah Satnam ji boys school कू ल / कॉलेज का पता (School /
Sirsa, Haryana
(School/College name should be as sirsa College Address)
per Class 12th Mark sheet/certificate)
कू ल / कॉलेज िपनकोड (School / College रोल नंबर 12वीं माणप के अनुसार
125055 17723897
Pincode) (Roll number as per 12th certificate)
पिरणाम मोड (Result Mode) Percentage पूणा क (Total Marks) 500.0
ातांक (Obtain Marks) 471.0 ितशत (Percentage) 94.20
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) 8222076679 ईमेल आईडी (Email ID) dharamdj5@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) 096682
लेन-दे न की ितिथ (Date of
परीा शु क (Exam Fee) 900.0 17-11-2023 21:32:07 PM
Transaction)
शु क जमा िकया गया (Fee Submitted
17-11-2023 21:29:17 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 : 152.58.124.113 Date of Downloading : 17-11-2023 21:36:47 PM