सं युत वे श परीा (मु य)

Joint Entrance Examination (Main)

JEE(Main)

APPLICATION NUMBER 240310578264

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)
TULSI AWAS VIKAS
COLONY PHASE 1
पता (Premises No/ Name) ईमेल पता (Email Address) ALOKSHUKLA2390@GMAIL.COM
PADRAUNA
KUSHINAGAR
उप-थानीयता (Sub-
थानीयता (Locality) PADRAUNA NA
Locality)(Optional)
दे श कोड (Country Code) 91 दे श (Country) INDIA
राय (State) UTTAR PRADESH िजला (District) Kushi Nagar
वै किपक संपक सू (Alternate
मोबाइल नंबर (Mobile Number) 91 - 7398259999 8858579632
Contact No.) (Optional)
िपन कोड (Pin Code) 274304
थायी पता (Permanent Address)
TULSI AWAS VIKAS
COLONY PHASE 1
पता (Premises No/ Name) थानीयता (Locality) PADRAUNA
PADRAUNA
KUSHINAGAR
उप-थानीयता (Sub-
NA दे श (Country) INDIA
Locality)(Optional):
राय (State) UTTAR PRADESH िजला (District) Kushi Nagar
िपन कोड (Pin Code) 274304
यितगत योरा (PERSONAL DETAILS)
अयथी की जम ितिथ (Candidate's
अयथी का नाम (Candidate's Name) ALOK SHUKLA 23-09-2006
Date of Birth)
िपता / अिभभावक का नाम (Father / TARKESHWAR माता / अिभभावक का नाम (Mother /
RAGINI SHUKLA
Guardian Name) SHUKLA 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 943092664610
Number)
PHOTOGRAPH
राय / केद शािसत दे श जहाँ से 12वीं /
समक उीण / उपिथत (State/ UT
UTTAR PRADESH े णी (Category ) GENERAL
from where 12th/ Equivalent
Passed/ Appearing)
या आपको मधुमेह ह  (Are You िनवास की जगह ( Place of
NO URBAN
Diabetic ? ) Residence )
यिद आप एक Pwd उमीदवार ह , तो या
आपके पास ब चमाक िवकलांगता है (If वािषक पािरवािरक आय ( Annual
NA 800000 AND ABOVE
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
Online Coaching मायम ( Medium of schooling in English
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 / TEACHING / िपता / अिभभावक योयता (Father /
Post Graduate
Guardian Occupation) RESEARCH Guardian Qualification)
माता / अिभभावक यवसाय (Mother / माता / अिभभावक योयता (Mother /
Self-Employment POST GRADUATE
Guardian Occupation) Guardian Qualification)
परीा राय-पहला िवकप (Exam परीा शहर-पहला िवकप (Exam
UTTAR PRADESH GORAKHPUR
State 1st Choice ) City 1st Choice )
परीा राय-दूसरा िवकप (Exam परीा शहर-दूसरा िवकप (Exam
UTTAR PRADESH LUCKNOW
State 2nd Choice ) City 2nd Choice )
परीा राय-तीसरा िवकप (Exam परीा शहर-तीसरा िवकप (Exam
UTTAR PRADESH VARANASI
State 3rd Choice ) City 3rd Choice )
परीा राय-चौथा िवकप (Exam परीा शहर-चौथा िवकप (Exam
UTTAR PRADESH KANPUR
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
Private Unaided UTTAR PRADESH
School / College) Examination State)
योयता परीा िजला (Qualifying COUNCIL FOR THE INDIAN SCHOOL
Kushi Nagar कू ल बोड (School Board)
Examination District) CERTIFICATE EXAMINATIONS
का 10वीं की माकशीट/माणप के
अनुसार िवालय/कॉलेज का नाम
कू ल / कॉलेज का पता (School / WX37+RC, Baharwalia, Padrauna, Uttar Pradesh
(School/College name should be as st thereses school padrauna
College Address) 274304
per Class 10th Mark
sheet/certificate)
रोल नंबर 10वीं माणप के अनुसार
कू ल / कॉलेज िपनकोड (School /
274304 (Roll number as per 10th 7714206
College Pincode)
certificate)
पिरणाम मोड (Result Mode) Percentage पूणा क (Total Marks) 600.0
ातांक (Obtain Marks) 417.0 ितशत (Percentage) 69.50
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)
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
योयता परीा (Qualifying Exam) Board of Secondary Urban
Schooling)
Education, New Delhi;
Council for the Indian
School Certificate
Examinations, New Delhi
etc.
कू ल / कॉलेज का कार (Type of योयता परीा राय (Qualifying
Private Unaided UTTAR PRADESH
School / College) Examination State)
योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY
Kushi Nagar कू ल बोड (School Board)
Examination District) EDUCATION
का 12वीं की माकशीट/माणप के
SMT BANNI DEVI SR
अनुसार िवालय/कॉलेज का नाम
SEC SCHOOL कू ल / कॉलेज का पता (School /
(School/College name should be as Barhara Ganj, Uttar Pradesh 274304
PADRAUNA College Address)
per Class 12th Mark
KUSHINAGAR
sheet/certificate)
रोल नंबर 12वीं माणप के अनुसार
कू ल / कॉलेज िपनकोड (School /
274304 (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
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) 8840921903 ईमेल आईडी (Email ID) SHUKLA.TARKESHWAR@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) CPADGSFTA4
लेन-दे न की ितिथ (Date of
परीा शु क (Exam Fee) 2000.0 01-01-1900 00:00:00 AM
Transaction)
शु क जमा िकया गया (Fee Submitted
20-11-2023 19:20:25 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 : 122.163.210.102 Date of Downloading : 10-01-2024 18:47:34 PM