सं युत वे श परीा (मु य)

Joint Entrance Examination (Main)

JEE(Main)
APPLICATION
240310033478
NUMBER
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)
CITY-BHABUA, VILL POST-AKHALASPUR,THANA- ईमेल पता (Email
पता (Premises No/ Name) IITIANNAITIK0011@GMAIL.COM
BHABUA,IKHLASPUR,KAIMUR BHABUA Address)
उप-थानीयता (Sub-
थानीयता (Locality) BHABUA KAIMUR NA
Locality)(Optional)
दे श कोड (Country Code) +91 दे श (Country) INDIA
राय (State) BIHAR िजला (District) Kaimur (Bhabua)
वै किपक संपक सू
मोबाइल नंबर (Mobile
+91 - 7543881421 (Alternate Contact 9097685124
Number)
No.) (Optional)
िपन कोड (Pin Code) 821101
थायी पता (Permanent Address)
CITY-BHABUA, VILL POST-AKHALASPUR,THANA-
पता (Premises No/ Name) थानीयता (Locality) BHABUA KAIMUR
BHABUA,IKHLASPUR,KAIMUR BHABUA
उप-थानीयता (Sub-
NA दे श (Country) INDIA
Locality)(Optional):
राय (State) BIHAR िजला (District) Kaimur (Bhabua)
िपन कोड (Pin Code) 821101
यितगत योरा (PERSONAL DETAILS)
अयथी की जम ितिथ
अयथी का नाम
NAITIK KUMAR (Candidate's Date of 05-05-2006
(Candidate's Name)
Birth)
िपता / अिभभावक का नाम माता / अिभभावक का नाम
(Father / Guardian SURENDRA SHARMA (Mother / Guardian SULEKHA DEVI
Name) Name)
िलंग (Gender) MALE राटीयता (Nationality ) INDIAN
पहचान के कार (Identity पहचान संया
ANY OTHER VALID GOVT IDENTITY WITH PHOTOGRAPH 778245494741
Type) (Identification Number)
राय / केद शािसत दे श
जहाँ से 12वीं / समक
उीण / उपिथत (State/ OBC-(NCL) AS PER CENTRAL
BIHAR े णी (Category )
UT from where 12th/ LIST
Equivalent Passed/
Appearing)
या आपको मधुमेह ह  िनवास की जगह ( Place of
NO RURAL
(Are You Diabetic ? ) Residence )
यिद आप एक Pwd
उमीदवार ह , तो या आपके
पास ब चमाक िवकलांगता है वािषक पािरवािरक आय (
NA 0-100000
(If you are a Pwd Annual Family Income )
Candidate, do you have
benchmark disability)?
योयता परीा म कू ली
तैयारी का तरीका ( Mode of िशा का मायम (
Online Coaching English
Preparation ) Medium of schooling in
qualifying exam )
परीा कद िववरण (Exam centre Details)
परीा के स के िलए
के िलए आवे दन (Apply
B.E./B.Tech आवे दन कर (Session Of Session 1 & Session 2
For)
Exam Apply For)
िपता / अिभभावक यवसाय िपता / अिभभावक योयता
(Father / Guardian BUSINESS (Father / Guardian Matriculate
Occupation) Qualification)
माता / अिभभावक यवसाय माता / अिभभावक योयता
(Mother / Guardian Others (Mother / Guardian GRADUATE
Occupation) Qualification)
परीा राय-पहला िवकप परीा शहर-पहला िवकप
BIHAR PATNA
(Exam State 1st Choice ) (Exam City 1st Choice )
परीा राय-दूसरा िवकप परीा शहर-दूसरा िवकप
BIHAR ARRAH
(Exam State 2nd Choice ) (Exam City 2nd Choice )
परीा राय-तीसरा िवकप परीा शहर-तीसरा िवकप
rd BIHAR rd MUZAFFARPUR
(Exam State 3 Choice ) (Exam City 3 Choice )
परीा राय-चौथा िवकप परीा शहर-चौथा िवकप
BIHAR SAMASTIPUR
(Exam State 4th Choice ) (Exam 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
उीण की िथित (Pass
Passed वष (Year of 2022
Status)
Passing/Appearing)
योयता परीा कू िलंग का थान (Place of
10 th or equivalent Urban
(Qualifying Exam) Schooling)
योयता परीा राय
कू ल / कॉलेज का कार
Private Unaided (Qualifying Examination BIHAR
(Type of School / College)
State)
योयता परीा िजला
CENTRAL BOARD OF
(Qualifying Examination Kaimur (Bhabua) कू ल बोड (School Board)
SECONDARY EDUCATION
District)
का 10वीं की
माकशीट/माणप के
अनुसार िवालय/कॉलेज का कू ल / कॉलेज का पता
Near SVP College, Ward No.-5,
नाम (School/College CHILDRENS GARDEN SCHOOL PO BHABUA KAIMUR BIHAR (School / College
Kaimur District, Bhabua, Bihar
name should be as per Address)
Class 10th Mark
sheet/certificate)
कू ल / कॉलेज िपनकोड रोल नंबर 10वीं माणप के
(School / College 821101 अनुसार (Roll number as 22156855
Pincode) per 10th certificate)
पिरणाम मोड (Result
Percentage पूणा क (Total Marks) 500.0
Mode)
ातांक (Obtain Marks) 446.0 ितशत (Percentage) 89.20
th
12वीं या समक योयता िववरण (12 or equivalent Qualification Details)
उीण / सिमिलत होने का
उीण की िथित (Pass
Appearing वष (Year of 2024
Status)
Passing/Appearing)
The final examination of the 10+2 system, conducted by any
योयता परीा recognized Central/ State Board, such as the Central Board of कू िलंग का थान (Place of
Rural
(Qualifying Exam) Secondary Education, New Delhi; Council for the Indian School Schooling)
Certificate Examinations, New Delhi etc.
योयता परीा राय
कू ल / कॉलेज का कार
Government School (Qualifying Examination BIHAR
(Type of School / College)
State)
योयता परीा िजला
BIHAR SCHOOL EXAMINATION
(Qualifying Examination Kaimur (Bhabua) कू ल बोड (School Board)
BOARD
District)
का 12वीं की
माकशीट/माणप के
अनुसार िवालय/कॉलेज का कू ल / कॉलेज का पता
AKHLASPUR, BHABUA, DISTT.-
नाम (School/College SMT. UDASI DEVI +2 HIGH SCHOOL (School / College
KAIMUR (BIHAR)
name should be as per Address)
Class 12th Mark
sheet/certificate)
कू ल / कॉलेज िपनकोड रोल नंबर 12वीं माणप के
(School / College 821101 अनुसार (Roll number as NA
Pincode) 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 (Are you a Twin and both
NO
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
7654844015 ईमेल आईडी (Email ID) dr.sulekhasharma0011@gmail.com
Number)
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 लेन-दे न आईडी
Online CPADFVBOT5
Mode) (Transaction ID)
लेन-दे न की ितिथ (Date of
परीा शु क (Exam Fee) 1800.0 01-01-1900 00:00:00 AM
Transaction)
शु क जमा िकया गया (Fee
07-11-2023 00:31:35 AM
Submitted 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 : 157.42.3.169 Date of Downloading : 07-11-2023 00:34:18 AM