सं युत वे श परीा (मु य)

Joint Entrance Examination (Main)

JEE(Main)
APPLICATION
240310080439
NUMBER
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) SHAMBAVI NILAYA ईमेल पता (Email Address) KISHANSHETTY.UDUPIKA20@GMAIL.COM
उप-थानीयता (Sub-
थानीयता (Locality) SASTHAN, UDUPI P. KALINGA RAO ROAD, PANDESHWARA
Locality)(Optional)
दे श कोड (Country Code) 91 दे श (Country) INDIA
राय (State) KARNATAKA िजला (District) Udupi
वै किपक संपक सू (Alternate
मोबाइल नंबर (Mobile Number) 91 - 7795704090 9606983178
Contact No.) (Optional)
िपन कोड (Pin Code) 576226
थायी पता (Permanent Address)
पता (Premises No/ Name) SHAMBAVI NILAYA थानीयता (Locality) SASTHAN, UDUPI
P. KALINGA RAO
उप-थानीयता (Sub-
ROAD, दे श (Country) INDIA
Locality)(Optional):
PANDESHWARA
राय (State) KARNATAKA िजला (District) Udupi
िपन कोड (Pin Code) 576226
यितगत योरा (PERSONAL DETAILS)
अयथी की जम ितिथ
अयथी का नाम (Candidate's Name) KISHAN SHETTY 13-10-2006
(Candidate's Date of Birth)
िपता / अिभभावक का नाम (Father / माता / अिभभावक का नाम (Mother
SUDHIR G SHETTY VANISHREE SHETTY
Guardian Name) / Guardian Name)
िलंग (Gender) MALE राटीयता (Nationality ) INDIAN
RATION CARD WITH पहचान संया (Identification
पहचान के कार (Identity Type) 260300265885
PHOTOGRAPH Number)
राय / केद शािसत दे श जहाँ से 12वीं
/ समक उीण / उपिथत (State/ UT
KARNATAKA े णी (Category ) GEN-EWS
from where 12th/ Equivalent
Passed/ Appearing)
या आपको मधुमेह ह  (Are You िनवास की जगह ( Place of
NO RURAL
Diabetic ? ) Residence )
यिद आप एक Pwd उमीदवार ह , तो
या आपके पास ब चमाक िवकलांगता है वािषक पािरवािरक आय ( Annual
NA 0-100000
(If you are a Pwd Candidate, do Family Income )
you have benchmark disability)?
योयता परीा म कू ली िशा का
तैयारी का तरीका ( Mode of Tutorial Classes in
मायम ( Medium of schooling in English
Preparation ) School
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
OTHERS Post Graduate
Guardian Occupation) / Guardian Qualification)
माता / अिभभावक यवसाय (Mother / माता / अिभभावक योयता (Mother
Not Applicable GRADUATE
Guardian Occupation) / Guardian Qualification)
परीा राय-पहला िवकप (Exam परीा शहर-पहला िवकप (Exam
KARNATAKA UDUPI/MANIPAL
State 1st Choice ) City 1st Choice )
परीा राय-दूसरा िवकप (Exam परीा शहर-दूसरा िवकप (Exam
KARNATAKA MANGALURU(MANGALORE)
State 2nd Choice ) City 2nd Choice )
परीा राय-तीसरा िवकप (Exam परीा शहर-तीसरा िवकप (Exam
KARNATAKA BENGALURU- URBAN
State 3rd Choice ) City 3rd Choice )
परीा राय-चौथा िवकप (Exam परीा शहर-चौथा िवकप (Exam
KARNATAKA CHIKMAGALUR
State 4th Choice ) City 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
उीण की िथित (Pass Status) Passed 2022
(Year 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 योयता परीा राय (Qualifying
Private Unaided KARNATAKA
School / College) Examination State)
योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY
Udupi कू ल बोड (School Board)
Examination District) EDUCATION
का 10वीं की माकशीट/माणप के
अनुसार िवालय/कॉलेज का नाम
S M S ENG MED कू ल / कॉलेज का पता (School /
(School/College name should be as Brahmavara, Udupi, Karnataka
SCHOOL College Address)
per Class 10th Mark
sheet/certificate)
रोल नंबर 10वीं माणप के अनुसार
कू ल / कॉलेज िपनकोड (School /
576213 (Roll number as per 10th 18165837
College Pincode)
certificate)
पिरणाम मोड (Result Mode) Percentage पूणा क (Total Marks) 500.0
ातांक (Obtain Marks) 479.0 ितशत (Percentage) 95.80
th
12वीं या समक योयता िववरण (12 or equivalent Qualification Details)
उीण / सिमिलत होने का वष
उीण की िथित (Pass Status) Appearing 2024
(Year of Passing/Appearing)
Intermediate or two-year
Pre-University
कू िलंग का थान (Place of
योयता परीा (Qualifying Exam) examination conducted Urban
Schooling)
by a recognized Board/
University.
कू ल / कॉलेज का कार (Type of योयता परीा राय (Qualifying
Private Unaided KARNATAKA
School / College) Examination State)
योयता परीा िजला (Qualifying KARNATAKA PRE-UNIVERSITY EDUCATION
Udupi कू ल बोड (School Board)
Examination District) EXAMINATION
का 12वीं की माकशीट/माणप के
अनुसार िवालय/कॉलेज का नाम VIDYODAYA PRE
कू ल / कॉलेज का पता (School /
(School/College name should be as UNIVERSITY Vadiraja Road, Udupi, Karnataka
College Address)
per Class 12th Mark COLLEGE
sheet/certificate)
रोल नंबर 12वीं माणप के अनुसार
कू ल / कॉलेज िपनकोड (School /
576101 (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 ह (Are you a Twin and both applying for JEE (MAIN) – NO
2024)?
आपातकालीन संपक िववरण प (Emergency Contact Details)
दे श (Country) INDIA दे श कोड (Country Code) +91
मोबाइल नंबर (Mobile Number) 9686869708 ईमेल आईडी (Email ID) kishanshettysudhirshetty@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) ZIC51784254286
लेन-दे न की ितिथ (Date of
परीा शु क (Exam Fee) 900.0 28-02-2024 19:59:37 PM
Transaction)
शु क जमा िकया गया (Fee Submitted 28-02-2024 19:58:55
On) PM
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 : 106.193.79.119 Date of Downloading : 28-02-2024 20:09:49 PM