सं युत वे श परीा (मु य)

Joint Entrance Examination (Main)

JEE(Main)

APPLICATION NUMBER 240310438834

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) 9/1142-J5 ईमेल पता (Email Address) KANIKESOMESH66@GMAIL.COM
उप-थानीयता (Sub-
थानीयता (Locality) YEMMIGANUR YSR NAGAR
Locality)(Optional)
दे श कोड (Country Code) 91 दे श (Country) INDIA
राय (State) ANDHRA PRADESH िजला (District) Kurnool
वै किपक संपक सू (Alternate
मोबाइल नंबर (Mobile Number) 91 - 9490782024 NA
Contact No.) (Optional)
िपन कोड (Pin Code) 518360
थायी पता (Permanent Address)
पता (Premises No/ Name) 9/1142-J5 थानीयता (Locality) YEMMIGANUR
उप-थानीयता (Sub-
YSR NAGAR दे श (Country) INDIA
Locality)(Optional):
राय (State) ANDHRA PRADESH िजला (District) Kurnool
िपन कोड (Pin Code) 518360
यितगत योरा (PERSONAL DETAILS)
अयथी की जम ितिथ (Candidate's
अयथी का नाम (Candidate's Name) SOMESH KANIKE 14-07-2007
Date of Birth)
िपता / अिभभावक का नाम (Father / माता / अिभभावक का नाम (Mother /
KRISHNA KANIKE PARVATHI KANIKE
Guardian Name) Guardian Name)
िलंग (Gender) MALE राटीयता (Nationality ) INDIAN
ANY OTHER VALID
पहचान संया (Identification
पहचान के कार (Identity Type) GOVT IDENTITY WITH 768297738518
Number)
PHOTOGRAPH
राय / केद शािसत दे श जहाँ से 12वीं /
समक उीण / उपिथत (State/ UT
ANDHRA PRADESH े 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
Self-Study 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 /
OTHERS Illiterate
Guardian Occupation) Guardian Qualification)
माता / अिभभावक यवसाय (Mother / माता / अिभभावक योयता (Mother /
Others ILLITERATE
Guardian Occupation) Guardian Qualification)
परीा राय-पहला िवकप (Exam State परीा शहर-पहला िवकप (Exam City
ANDHRA PRADESH KURNOOL
1st Choice ) 1st Choice )
परीा राय-दूसरा िवकप (Exam State परीा शहर-दूसरा िवकप (Exam City
ANDHRA PRADESH NANDYAL
2nd Choice ) 2nd Choice )
परीा राय-तीसरा िवकप (Exam State परीा शहर-तीसरा िवकप (Exam City
ANDHRA PRADESH ANANTAPUR
3rd Choice ) 3rd Choice )
परीा राय-चौथा िवकप (Exam State परीा शहर-चौथा िवकप (Exam City
ANDHRA PRADESH KADAPA
4th Choice ) 4th 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) Rural
कू ल / कॉलेज का कार (Type of School / Jawahar Navodaya योयता परीा राय (Qualifying
ANDHRA PRADESH
College) Vidyalaya (JNVs) Examination State)
योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY
Kurnool कू ल बोड (School Board)
Examination District) EDUCATION
का 10वीं की माकशीट/माणप के NAVODAYA
अनुसार िवालय/कॉलेज का नाम VIDYALAYA कू ल / कॉलेज का पता (School /
BANAVASI YEMMIGANUR
(School/College name should be as per YEMMIGANUR College Address)
Class 10th Mark sheet/certificate) KURNOOL AP
कू ल / कॉलेज िपनकोड (School / College रोल नंबर 10वीं माणप के अनुसार
518360 20120031
Pincode) (Roll number as per 10th certificate)
पिरणाम मोड (Result Mode) Percentage पूणा क (Total Marks) 500.0
ातांक (Obtain Marks) 421.0 ितशत (Percentage) 84.20
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)
Intermediate or two-year
Pre-University examination
योयता परीा (Qualifying Exam) कू िलंग का थान (Place of Schooling) Rural
conducted by a recognized
Board/ University.
कू ल / कॉलेज का कार (Type of School / Jawahar Navodaya योयता परीा राय (Qualifying
ANDHRA PRADESH
College) Vidyalaya (JNVs) Examination State)
योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY
Kurnool कू ल बोड (School Board)
Examination District) EDUCATION
का 12वीं की माकशीट/माणप के NAVODAYA
अनुसार िवालय/कॉलेज का नाम VIDYALAYA कू ल / कॉलेज का पता (School /
BANAVASI YEMMIGANUR
(School/College name should be as per YEMMIGANUR College Address)
Class 12th Mark sheet/certificate) KURNOOL AP
कू ल / कॉलेज िपनकोड (School / College रोल नंबर 12वीं माणप के अनुसार
518360 NA
Pincode) (Roll 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) 9966887849 ईमेल आईडी (Email ID) khanyemmiganur1@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) Online लेन-दे न आईडी (Transaction ID) ZHMP1536000023
लेन-दे न की ितिथ (Date of
परीा शु क (Exam Fee) 900.0 15-11-2023 12:01:34 PM
Transaction)
शु क जमा िकया गया (Fee Submitted
15-11-2023 12:01:06 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 : 117.204.66.47 Date of Downloading : 15-11-2023 12:04:20 PM