सं युत वे श परीा (मु य)

Joint Entrance Examination (Main)

JEE(Main)

APPLICATION NUMBER 240311013275

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)
VILL PO-CHIKSI PS-
पता (Premises No/ Name) ईमेल पता (Email Address) ASJADMODELER@GMAIL.COM
SIGORI
उप-थानीयता (Sub-
थानीयता (Locality) PALIGANJ NA
Locality)(Optional)
दे श कोड (Country Code) +91 दे श (Country) INDIA
राय (State) BIHAR िजला (District) Patna
वै किपक संपक सू (Alternate Contact
मोबाइल नंबर (Mobile Number) +91 - 9102528440 NA
No.) (Optional)
िपन कोड (Pin Code) 801110
थायी पता (Permanent Address)
VILL PO-CHIKSI PS-
पता (Premises No/ Name) थानीयता (Locality) PALIGANJ
SIGORI
उप-थानीयता (Sub-Locality)(Optional): NA दे श (Country) INDIA
राय (State) BIHAR िजला (District) Patna
िपन कोड (Pin Code) 801110
यितगत योरा (PERSONAL DETAILS)
अयथी की जम ितिथ (Candidate's
अयथी का नाम (Candidate's Name) MD ASJAD ALI 10-01-2007
Date of Birth)
िपता / अिभभावक का नाम (Father / माता / अिभभावक का नाम (Mother /
ASHARAF ANSARI SABANA KHATUN
Guardian Name) Guardian Name)
िलंग (Gender) MALE राटीयता (Nationality ) INDIAN
ANY OTHER VALID
पहचान के कार (Identity Type) GOVT IDENTITY WITH पहचान संया (Identification Number) 724902182352
PHOTOGRAPH
राय / केद शािसत दे श जहाँ से 12वीं /
समक उीण / उपिथत (State/ UT from
BIHAR े णी (Category ) OBC-(NCL) AS PER CENTRAL LIST
where 12th/ Equivalent Passed/
Appearing)
या आपको मधुमेह ह  (Are You
NO िनवास की जगह ( Place of Residence ) RURAL
Diabetic ? )
यिद आप एक Pwd उमीदवार ह , तो या
आपके पास ब चमाक िवकलांगता है (If you वािषक पािरवािरक आय ( Annual Family
NA 0-100000
are a Pwd Candidate, do you have 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 /
NOT APPLICABLE Not Applicable
Guardian Occupation) Guardian Qualification)
माता / अिभभावक यवसाय (Mother / माता / अिभभावक योयता (Mother /
Not Applicable NOT APPLICABLE
Guardian Occupation) Guardian Qualification)
परीा राय-पहला िवकप (Exam State परीा शहर-पहला िवकप (Exam City
BIHAR PATNA
1st Choice ) 1st Choice )
परीा राय-दूसरा िवकप (Exam State परीा शहर-दूसरा िवकप (Exam City
BIHAR GAYA
2nd Choice ) 2nd Choice )
परीा राय-तीसरा िवकप (Exam State परीा शहर-तीसरा िवकप (Exam City
BIHAR ARRAH
3rd Choice ) 3rd Choice )
परीा राय-चौथा िवकप (Exam State परीा शहर-चौथा िवकप (Exam City
BIHAR MUZAFFARPUR
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 / योयता परीा राय (Qualifying
Private Unaided BIHAR
College) Examination State)
योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY
Jehanabad कू ल बोड (School Board)
Examination District) EDUCATION
का 10वीं की माकशीट/माणप के
अनुसार िवालय/कॉलेज का नाम bal vidya mandir babhana कू ल / कॉलेज का पता (School / College
babhana jehanabad
(School/College name should be as per jehanabad bihar Address)
Class 10th Mark sheet/certificate)
कू ल / कॉलेज िपनकोड (School / College रोल नंबर 10वीं माणप के अनुसार (Roll
65799 22155810
Pincode) number as per 10th certificate)
पिरणाम मोड (Result Mode) Percentage पूणा क (Total Marks) 500.0
ातांक (Obtain Marks) 439.0 ितशत (Percentage) 87.80
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
योयता परीा (Qualifying Exam) examination conducted by कू िलंग का थान (Place of Schooling) Rural
a recognized Board/
University.
कू ल / कॉलेज का कार (Type of School / योयता परीा राय (Qualifying
Private Unaided BIHAR
College) Examination State)
योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY
Patna कू ल बोड (School Board)
Examination District) EDUCATION
का 12वीं की माकशीट/माणप के
LITTLE FLOWER
अनुसार िवालय/कॉलेज का नाम कू ल / कॉलेज का पता (School / College
SCHOOL PALIGANJ at po ps-paliganj patna
(School/College name should be as per Address)
PATNA
Class 12th Mark sheet/certificate)
कू ल / कॉलेज िपनकोड (School / College रोल नंबर 12वीं माणप के अनुसार (Roll
801110 NA
Pincode) 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) 8809988957 ईमेल आईडी (Email ID) mdamjad8011@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) 172547894
परीा शु क (Exam Fee) 900.0 लेन-दे न की ितिथ (Date of Transaction) 25-11-2023 17:27:42 PM
शु क जमा िकया गया (Fee Submitted
25-11-2023 17:26:58 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 : 106.76.239.20 Date of Downloading : 25-11-2023 17:28:03 PM