सं युत वे श परीा (मु य)

Joint Entrance Examination (Main)

JEE(Main)

APPLICATION NUMBER 240310560150

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)
AMBUJA CEMENT
पता (Premises No/ Name) ईमेल पता (Email Address) ANILATHORAT00@GMAIL.COM
LIMITED COLONY
उप-थानीयता (Sub-
थानीयता (Locality) BALODA BAZAAR RAWAN
Locality)(Optional)
दे श कोड (Country Code) +91 दे श (Country) INDIA
राय (State) CHHATTISGARH िजला (District) Balodabazar-Bhatapara
वै किपक संपक सू (Alternate
मोबाइल नंबर (Mobile Number) +91 - 9893565506 9425518177
Contact No.) (Optional)
िपन कोड (Pin Code) 493331
थायी पता (Permanent Address)
AMBUJA CEMENT
पता (Premises No/ Name) थानीयता (Locality) BALODA BAZAAR
LIMITED COLONY
उप-थानीयता (Sub-
RAWAN दे श (Country) INDIA
Locality)(Optional):
राय (State) CHHATTISGARH िजला (District) Balodabazar-Bhatapara
िपन कोड (Pin Code) 493331
यितगत योरा (PERSONAL DETAILS)
अयथी की जम ितिथ (Candidate's
अयथी का नाम (Candidate's Name) ATHARV THORAT 05-05-2006
Date of Birth)
िपता / अिभभावक का नाम (Father / माता / अिभभावक का नाम (Mother /
YOGESH THORAT ANILA THORAT
Guardian Name) Guardian Name)
िलंग (Gender) MALE राटीयता (Nationality ) INDIAN
CLASS XII ADMIT CARD पहचान संया (Identification
पहचान के कार (Identity Type) BHADRAKAALI1977
ISSUED BY THE BOARD Number)
राय / केद शािसत दे श जहाँ से 12वीं /
समक उीण / उपिथत (State/ UT
CHHATTISGARH े णी (Category ) GENERAL
from where 12th/ Equivalent Passed/
Appearing)
या आपको मधुमेह ह  (Are You िनवास की जगह ( Place of Residence
NO RURAL
Diabetic ? ) )
यिद आप एक Pwd उमीदवार ह , तो या
आपके पास ब चमाक िवकलांगता है (If you वािषक पािरवािरक आय ( Annual
NA 800000 AND ABOVE
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 2
(Session Of Exam Apply For)
िपता / अिभभावक यवसाय (Father / िपता / अिभभावक योयता (Father /
TEACHING / RESEARCH Post Graduate
Guardian Occupation) Guardian Qualification)
माता / अिभभावक यवसाय (Mother / माता / अिभभावक योयता (Mother /
Teaching / Research POST GRADUATE
Guardian Occupation) Guardian Qualification)
परीा राय-पहला िवकप (Exam State परीा शहर-पहला िवकप (Exam City
CHHATTISGARH JAGDALPUR
1st Choice ) 1st Choice )
परीा राय-दूसरा िवकप (Exam State परीा शहर-दूसरा िवकप (Exam City
CHHATTISGARH BILASPUR(CHHATTISGARH)
2nd Choice ) 2nd Choice )
परीा राय-तीसरा िवकप (Exam State परीा शहर-तीसरा िवकप (Exam
CHHATTISGARH RAIPUR
3rd Choice ) City 3rd Choice )
परीा राय-चौथा िवकप (Exam State परीा शहर-चौथा िवकप (Exam City
CHHATTISGARH BHILAI NAGAR/DURG
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
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 Rural
Schooling)
कू ल / कॉलेज का कार (Type of School योयता परीा राय (Qualifying
Private Unaided CHHATTISGARH
/ College) Examination State)
योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY
Balodabazar-Bhatapara कू ल बोड (School Board)
Examination District) EDUCATION
का 10वीं की माकशीट/माणप के
अनुसार िवालय/कॉलेज का नाम कू ल / कॉलेज का पता (School /
Ambuja vidya peeth rawan,baloda bazaar
(School/College name should be as College Address)
per Class 10th Mark sheet/certificate)
रोल नंबर 10वीं माणप के अनुसार
कू ल / कॉलेज िपनकोड (School / College
493331 (Roll number as per 10th 12123832
Pincode)
certificate)
पिरणाम मोड (Result Mode) Percentage पूणा क (Total Marks) 500.0
ातांक (Obtain Marks) 412.0 ितशत (Percentage) 82.40
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 Rural
Schooling)
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 CHHATTISGARH
/ College) Examination State)
योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY
Balodabazar-Bhatapara 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 /
ambuja vidya peeth rawan,baloda bazaar
(School/College name should be as College Address)
per Class 12th Mark sheet/certificate)
रोल नंबर 12वीं माणप के अनुसार
कू ल / कॉलेज िपनकोड (School / College
493331 (Roll number as per 12th NA
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 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) 9752627034 ईमेल आईडी (Email ID) atharvt55@gmail.com
उमीदवार ारा अपलोड की गई छिवयां (IMAGES UPLOADED BY THE CANDIDATE)

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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) CPADGNONE9
लेन-दे न की ितिथ (Date of
परीा शु क (Exam Fee) 2000.0 17-11-2023 16:42:59 PM
Transaction)
शु क जमा िकया गया (Fee Submitted
17-11-2023 16:41:21 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 : 59.95.95.53 Date of Downloading : 17-11-2023 16:45:16 PM