सं युत वे श परीा (मु य)

Joint Entrance Examination (Main)

JEE(Main)

APPLICATION NUMBER 240310037541

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) VACHAPURAM HOUSE ईमेल पता (Email Address) MHD.IRFAN.SHIBLI@GMAIL.COM
उप-थानीयता (Sub-
थानीयता (Locality) CHULLIKODE NA
Locality)(Optional)
दे श कोड (Country Code) +91 दे श (Country) INDIA
राय (State) KERALA िजला (District) Malappuram
वै किपक संपक सू (Alternate
मोबाइल नंबर (Mobile Number) +91 - 7907240268 9544112519
Contact No.) (Optional)
िपन कोड (Pin Code) 673641
थायी पता (Permanent Address)
पता (Premises No/ Name) VACHAPURAM HOUSE थानीयता (Locality) CHULLIKODE
उप-थानीयता (Sub-
NA दे श (Country) INDIA
Locality)(Optional):
राय (State) KERALA िजला (District) Malappuram
िपन कोड (Pin Code) 673641
यितगत योरा (PERSONAL DETAILS)
MUHAMMED IRFAN अयथी की जम ितिथ (Candidate's
अयथी का नाम (Candidate's Name) 20-07-2005
SHIBILI V P Date of Birth)
िपता / अिभभावक का नाम (Father / SHIHABUDHEEN माता / अिभभावक का नाम (Mother /
SUFAIRA
Guardian Name) VACHAPURAM 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 668282227847
Number)
PHOTOGRAPH
राय / केद शािसत दे श जहाँ से 12वीं /
समक उीण / उपिथत (State/ UT
KERALA े णी (Category ) OBC-(NCL) AS PER CENTRAL LIST
from 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
NA 0-100000
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 Of Exam Apply For)
िपता / अिभभावक यवसाय (Father / िपता / अिभभावक योयता (Father /
OTHERS Matriculate
Guardian Occupation) Guardian Qualification)
माता / अिभभावक यवसाय (Mother / माता / अिभभावक योयता (Mother /
Others MATRICULATE
Guardian Occupation) Guardian Qualification)
परीा राय-पहला िवकप (Exam State परीा शहर-पहला िवकप (Exam City
KERALA MALAPPURAM
1st Choice ) 1st Choice )
परीा राय-दूसरा िवकप (Exam State परीा शहर-दूसरा िवकप (Exam City
KERALA KOZHIKODE/CALICUT
2nd Choice ) 2nd Choice )
परीा राय-तीसरा िवकप (Exam State परीा शहर-तीसरा िवकप (Exam City
KERALA PALAKKAD
3rd Choice ) 3rd Choice )
परीा राय-चौथा िवकप (Exam State परीा शहर-चौथा िवकप (Exam City
KERALA THRISSUR
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 2021
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
Government Aided Private KERALA
College) Examination State)
योयता परीा िजला (Qualifying KERALA BOARD OF HIGHER SEC.
Malappuram 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 /
Ppmhss kottukkara KOTTUKKARA, kondotty, malappuram
(School/College name should be as per College Address)
Class 10th Mark sheet/certificate)
कू ल / कॉलेज िपनकोड (School / College रोल नंबर 10वीं माणप के अनुसार
673638 502368
Pincode) (Roll number as per 10th certificate)
अिधकतम ग े ड वाइंट (Max Grade
पिरणाम मोड (Result Mode) CGPA 9.0
Point)
संचयी ितशत (Cumulative
सीजीपीए ात िकया (Obtained CGPA) 9.0 99.9
Percentage)
12वीं या समक योयता िववरण (12th or equivalent Qualification Details)
उीण / सिमिलत होने का वष (Year of
उीण की िथित (Pass Status) Passed 2023
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) Rural
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
Government Aided Private KERALA
College) Examination State)
योयता परीा िजला (Qualifying KERALA BOARD OF PUBLIC
Malappuram कू ल बोड (School Board)
Examination District) EXAMINATION
का 12वीं की माकशीट/माणप के
अनुसार िवालय/कॉलेज का नाम कू ल / कॉलेज का पता (School /
Ppmhss kottukkara Kottukkara, kondotty, malappuram
(School/College name should be as per College Address)
Class 12th Mark sheet/certificate)
कू ल / कॉलेज िपनकोड (School / College रोल नंबर 12वीं माणप के अनुसार
673638 22311264
Pincode) (Roll number as per 12th certificate)
पिरणाम मोड (Result Mode) Percentage पूणा क (Total Marks) 1200.0
ातांक (Obtain Marks) 879.0 ितशत (Percentage) 73.25
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) 7558812022 ईमेल आईडी (Email ID) vpirfanshibli@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) CPADFPWYY3
 लेन-दे न की ितिथ (Date of
परीा शु क (Exam Fee) 900.0 01-01-1900 00:00:00 AM
Transaction)
शु क जमा िकया गया (Fee Submitted
04-11-2023 11:47:09 AM
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 : 103.151.188.206 Date of Downloading : 19-03-2024 12:37:06 PM