सं युत वे श परीा (मु य)

Joint Entrance Examination (Main)

JEE(Main)
APPLICATION
240320244635
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)
ROOM NO 10, SECOND
पता (Premises No/ Name) ईमेल पता (Email Address) MOKSHITABARKHAJAIN@GMAIL.COM
FLOOR, AMIT SAGAR
उप-थानीयता (Sub-
थानीयता (Locality) DOMBIVLI EAST PANCHAYAT BAWDI, SARASWAT COLONY
Locality)(Optional)
दे श कोड (Country Code) 91 दे श (Country) INDIA
राय (State) MAHARASHTRA िजला (District) Thane
वै किपक संपक सू (Alternate
मोबाइल नंबर (Mobile Number) 91 - 9082120106 9167378920
Contact No.) (Optional)
िपन कोड (Pin Code) 421201
थायी पता (Permanent Address)
ROOM NO 10, SECOND
पता (Premises No/ Name) थानीयता (Locality) DOMBIVLI EAST
FLOOR, AMIT SAGAR
उप-थानीयता (Sub- PANCHAYAT BAWDI,
दे श (Country) INDIA
Locality)(Optional): SARASWAT COLONY
राय (State) MAHARASHTRA िजला (District) Thane
िपन कोड (Pin Code) 421201
यितगत योरा (PERSONAL DETAILS)
अयथी की जम ितिथ (Candidate's
अयथी का नाम (Candidate's Name) MOKSHITA JAIN 14-11-2006
Date of Birth)
िपता / अिभभावक का नाम (Father / PRAKASH माता / अिभभावक का नाम (Mother /
BARKHA JAIN
Guardian Name) ROSHANLAL JAIN Guardian Name)
िलंग (Gender) FEMALE राटीयता (Nationality ) INDIAN
ANY OTHER VALID
पहचान संया (Identification
पहचान के कार (Identity Type) GOVT IDENTITY WITH 779328583152
Number)
PHOTOGRAPH
राय / केद शािसत दे श जहाँ से 12वीं /
समक उीण / उपिथत (State/ UT
MAHARASHTRA े णी (Category ) GENERAL
from where 12th/ Equivalent
Passed/ Appearing)
या आपको मधुमेह ह  (Are You िनवास की जगह ( Place of
NO URBAN
Diabetic ? ) Residence )
यिद आप एक Pwd उमीदवार ह , तो या
आपके पास ब चमाक िवकलांगता है (If वािषक पािरवािरक आय ( Annual
NA 400001-500000
you are a Pwd Candidate, do you Family Income )
have benchmark disability)?
योयता परीा म कू ली िशा का
तैयारी का तरीका ( Mode of
Self-Study मायम ( Medium of schooling in English
Preparation )
qualifying exam )
परीा कद िववरण (Exam centre Details)
परीा के स के िलए आवे दन कर
के िलए आवे दन (Apply For) B.Arch., B.E./B.Tech Session 2
(Session Of Exam Apply For)
िपता / अिभभावक यवसाय (Father / िपता / अिभभावक योयता (Father /
BUSINESS Graduate
Guardian Occupation) Guardian Qualification)
माता / अिभभावक यवसाय (Mother / माता / अिभभावक योयता (Mother
Others GRADUATE
Guardian Occupation) / Guardian Qualification)
परीा राय-पहला िवकप (Exam परीा शहर-पहला िवकप (Exam
MAHARASHTRA THANE
State 1st Choice ) City 1st Choice )
परीा राय-दूसरा िवकप (Exam परीा शहर-दूसरा िवकप (Exam
MAHARASHTRA MUMBAI/NAVI MUMBAI
State 2nd Choice ) City 2nd Choice )
परीा राय-तीसरा िवकप (Exam परीा शहर-तीसरा िवकप (Exam
MAHARASHTRA NASHIK
State 3rd Choice ) City 3rd Choice )
परीा राय-चौथा िवकप (Exam परीा शहर-चौथा िवकप (Exam
MAHARASHTRA PUNE
State 4th Choice ) City 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
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 Urban
Schooling)
कू ल / कॉलेज का कार (Type of योयता परीा राय (Qualifying
Private Unaided MAHARASHTRA
School / College) Examination State)
योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY
Thane कू ल बोड (School Board)
Examination District) EDUCATION
का 10वीं की माकशीट/माणप के
अनुसार िवालय/कॉलेज का नाम S.V.Joshi High School (Old Building), Vidya
Blossom international कू ल / कॉलेज का पता (School /
(School/College name should be as Sankul, Nehru Rd, Pendse Nagar, Dombivli East,
school College Address)
per Class 10th Mark Dombivli, Maharashtra 421201
sheet/certificate)
रोल नंबर 10वीं माणप के अनुसार
कू ल / कॉलेज िपनकोड (School /
421201 (Roll number as per 10th 15188784
College Pincode)
certificate)
पिरणाम मोड (Result Mode) Percentage पूणा क (Total Marks) 600.0
ातांक (Obtain Marks) 528.0 ितशत (Percentage) 88.00
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 Urban
Schooling)
Education, New Delhi;
Council for the Indian
School Certificate
Examinations, New Delhi
etc.
कू ल / कॉलेज का कार (Type of योयता परीा राय (Qualifying
Private Unaided MAHARASHTRA
School / College) Examination State)
योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY
Thane 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 / PT Colony, Gandhinagar, Village Nandivali,
(School/College name should be as Royal International school
College Address) Dombivli, Maharashtra 421201
per Class 12th Mark
sheet/certificate)
रोल नंबर 12वीं माणप के अनुसार
कू ल / कॉलेज िपनकोड (School /
421201 (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) 9224283557 ईमेल आईडी (Email ID) prakashjainyash2@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) 252045087
लेन-दे न की ितिथ (Date of
परीा शु क (Exam Fee) 1600.0 01-03-2024 16:46:14 PM
Transaction)
शु क जमा िकया गया (Fee Submitted
01-03-2024 16:44:29 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 : 206.84.225.139 Date of Downloading : 01-03-2024 16:47:34 PM