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THE CANDIDATE IS REQUESTED TO RETAIN THE PRINTOUT OF THE CONFIRMATION PAGE FOR FUTURE REFERENCE. यितगत योरा (Contact Details) वतमान पता (Present Address) पता (Premises No/ Name) HOUSE NO.25 ईमेल पता (Email Address) CY5650092@GMAIL.COM थानीयता (Locality) CAMPIERGANJ उप-थानीयता (Sub-Locality)(Optional) WARD NO.2 BHAURABARI दे श कोड (Country Code) 91 दे श (Country) INDIA राय (State) UTTAR PRADESH िजला (District) Gorakhpur वै किपक संपक सू (Alternate Contact मोबाइल नंबर (Mobile Number) 91 - 7317639652 8957256032 No.) (Optional) िपन कोड (Pin Code) 273158 थायी पता (Permanent Address) पता (Premises No/ Name) HOUSE NO.25 थानीयता (Locality) CAMPIERGANJ उप-थानीयता (Sub- WARD NO.2 दे श (Country) INDIA Locality)(Optional): BHAURABARI राय (State) UTTAR PRADESH िजला (District) Gorakhpur िपन कोड (Pin Code) 273158 यितगत योरा (PERSONAL DETAILS) अयथी की जम ितिथ (Candidate's Date अयथी का नाम (Candidate's Name) PRABHAKAR YADAV 07-08-2006 of Birth) िपता / अिभभावक का नाम (Father / माता / अिभभावक का नाम (Mother / CHANDRIKA YADAV SUBHADRA YADAV Guardian Name) Guardian Name) िलंग (Gender) MALE राटीयता (Nationality ) INDIAN ANY OTHER VALID पहचान के कार (Identity Type) GOVT IDENTITY WITH पहचान संया (Identification Number) 652299840830 PHOTOGRAPH राय / केद शािसत दे श जहाँ से 12वीं / समक उीण / उपिथत (State/ UT UTTAR PRADESH े 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 उमीदवार ह , तो या आपके पास ब चमाक िवकलांगता है (If you वािषक पािरवािरक आय ( Annual Family NA 400001-500000 are a Pwd Candidate, do you have Income ) benchmark disability)? योयता परीा म कू ली िशा का मायम ( तैयारी का तरीका ( Mode of Preparation Self-Study Medium of schooling in qualifying exam English ) ) परीा कद िववरण (Exam centre Details) परीा के स के िलए आवे दन कर (Session के िलए आवे दन (Apply For) B.E./B.Tech Session 1 Of Exam Apply For) िपता / अिभभावक यवसाय (Father / िपता / अिभभावक योयता (Father / BUSINESS Others Guardian Occupation) Guardian Qualification) माता / अिभभावक यवसाय (Mother / माता / अिभभावक योयता (Mother / Agriculture OTHERS Guardian Occupation) Guardian Qualification) परीा राय-पहला िवकप (Exam State परीा शहर-पहला िवकप (Exam City 1st UTTAR PRADESH GORAKHPUR 1st Choice ) Choice ) परीा राय-दूसरा िवकप (Exam State परीा शहर-दूसरा िवकप (Exam City 2nd UTTAR PRADESH LUCKNOW 2nd Choice ) Choice ) परीा राय-तीसरा िवकप (Exam State परीा शहर-तीसरा िवकप (Exam City 3rd UTTAR PRADESH BASTI 3rd Choice ) Choice ) परीा राय-चौथा िवकप (Exam State परीा शहर-चौथा िवकप (Exam City 4th UTTAR PRADESH FIROZABAD 4th Choice ) Choice ) न प मायम (Question Paper Medium) English th 10वीं या समक योयता िववरण (10 or equivalent Qualification Details) उीण / सिमिलत होने का वष (Year of उीण की िथित (Pass Status) Passed 2022 Passing/Appearing) योयता परीा (Qualifying Exam) 10 th or equivalent कू िलंग का थान (Place of Schooling) Urban कू ल / कॉलेज का कार (Type of School / योयता परीा राय (Qualifying Private Unaided UTTAR PRADESH College) Examination State) योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY Gorakhpur कू ल बोड (School Board) Examination District) EDUCATION का 10वीं की माकशीट/माणप के अनुसार िवालय/कॉलेज का नाम कू ल / कॉलेज का पता (School / College U S academy and Instt Rajpur campierganj 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 70519 23161393 Pincode) number as per 10th certificate) पिरणाम मोड (Result Mode) Percentage पूणा क (Total Marks) 500.0 ातांक (Obtain Marks) 469.0 ितशत (Percentage) 93.80 th 12वीं या समक योयता िववरण (12 or equivalent Qualification Details) उीण / सिमिलत होने का वष (Year of उीण 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 योयता परीा (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 / योयता परीा राय (Qualifying Private Unaided UTTAR PRADESH College) Examination State) योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY Gorakhpur कू ल बोड (School Board) Examination District) EDUCATION का 12वीं की माकशीट/माणप के अनुसार िवालय/कॉलेज का नाम कू ल / कॉलेज का पता (School / College RPM academy Green City 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 273015 NA Pincode) number as per 12th certificate) अितिरत 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) 9026423243 ईमेल आईडी (Email ID) ysugandha99@gmail.com उमीदवार ा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) CPADGUJSJ8 परीा शु क (Exam Fee) 900.0 लेन-दे न की ितिथ (Date of Transaction) 01-01-1900 00:00:00 AM शु क जमा िकया गया (Fee Submitted 21-11-2023 19:06:26 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 : 122.163.199.223 Date of Downloading : 21-11-2023 19:07:39 PM