सं युत वे श परीा (मु य)

Joint Entrance Examination (Main)

JEE(Main)

APPLICATION NUMBER 240310894586

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)
KHOTTA TOLA
पता (Premises No/ Name) ईमेल पता (Email Address) AM3340071@GMAIL.COM
SINGHARIA
उप-थानीयता (Sub-
थानीयता (Locality) GORAKHPUR KUNRAGHAT
Locality)(Optional)
दे श कोड (Country Code) 91 दे श (Country) INDIA
राय (State) UTTAR PRADESH िजला (District) Gorakhpur
वै किपक संपक सू (Alternate Contact
मोबाइल नंबर (Mobile Number) 91 - 8009778389 9956916569
No.) (Optional)
िपन कोड (Pin Code) 273008
थायी पता (Permanent Address)
KHOTTA TOLA
पता (Premises No/ Name) थानीयता (Locality) GORAKHPUR
SINGHARIA
उप-थानीयता (Sub-
KUNRAGHAT दे श (Country) INDIA
Locality)(Optional):
राय (State) UTTAR PRADESH िजला (District) Gorakhpur
िपन कोड (Pin Code) 273008
यितगत योरा (PERSONAL DETAILS)
अयथी की जम ितिथ (Candidate's
अयथी का नाम (Candidate's Name) ADITYA MISHRA 12-12-2006
Date of Birth)
िपता / अिभभावक का नाम (Father / SHARAD CHANDAR माता / अिभभावक का नाम (Mother /
RANI MISHRA
Guardian Name) MISHRA 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) 849259051782
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
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 300001-400000
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
Others 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 2
(Session Of Exam Apply For)
िपता / अिभभावक यवसाय (Father / िपता / अिभभावक योयता (Father /
LAW PRACTICE Graduate
Guardian Occupation) Guardian Qualification)
माता / अिभभावक यवसाय (Mother / माता / अिभभावक योयता (Mother /
Others POST GRADUATE
Guardian Occupation) Guardian Qualification)
परीा राय-पहला िवकप (Exam State परीा शहर-पहला िवकप (Exam City
UTTAR PRADESH GORAKHPUR
1st Choice ) 1st Choice )
परीा राय-दूसरा िवकप (Exam State परीा शहर-दूसरा िवकप (Exam City
UTTAR PRADESH AZAMGARH
2nd Choice ) 2nd Choice )
परीा राय-तीसरा िवकप (Exam State परीा शहर-तीसरा िवकप (Exam City
UTTAR PRADESH AMBEDKAR NAGAR
3rd Choice ) 3rd Choice )
परीा राय-चौथा िवकप (Exam State परीा शहर-चौथा िवकप (Exam City
UTTAR PRADESH BASTI
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 2022
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 UTTAR PRADESH
College) Examination State)
योयता परीा िजला (Qualifying COUNCIL FOR THE INDIAN SCHOOL
Gorakhpur 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 / College
Hp children academy Civil lines gorakhpur
(School/College name should be as per Address)
Class 10th Mark sheet/certificate)
कू ल / कॉलेज िपनकोड (School / College रोल नंबर 10वीं माणप के अनुसार (Roll
209601 7595141
Pincode) number as per 10th certificate)
अिधकतम ग े ड वाइंट (Max Grade
पिरणाम मोड (Result Mode) CGPA 1.0
Point)
संचयी ितशत (Cumulative
सीजीपीए ात िकया (Obtained CGPA) 1.0 2
Percentage)
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)
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 UTTAR PRADESH
College) Examination State)
योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY
Gorakhpur कू ल बोड (School Board)
Examination District) EDUCATION
का 12वीं की माकशीट/माणप के
अनुसार िवालय/कॉलेज का नाम कू ल / कॉलेज का पता (School / College
Academic global school Padri bazar Jungle dushad gorakhpur
(School/College name should be as per Address)
Class 12th Mark sheet/certificate)
कू ल / कॉलेज िपनकोड (School / College रोल नंबर 12वीं माणप के अनुसार (Roll
273014 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) 8423999976 ईमेल आईडी (Email ID) sharadchandramishra85@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) CPADGYTJI9
परीा शु क (Exam Fee) 2000.0 लेन-दे न की ितिथ (Date of Transaction) 23-11-2023 18:48:43 PM
शु क जमा िकया गया (Fee Submitted
23-11-2023 18:48:31 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 : 117.98.32.80 Date of Downloading : 24-11-2023 22:39:25 PM