सं युत वे श परीा (मु य)

Joint Entrance Examination (Main)

JEE(Main)

APPLICATION NUMBER 240310497340

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) A-138 ईमेल पता (Email Address) [email protected]
INDRAVIHAR COLONY उप-थानीयता (Sub-
थानीयता (Locality) NA
AIRPORT ROAD Locality)(Optional)
दे श कोड (Country Code) 91 दे श (Country) INDIA
राय (State) MADHYA PRADESH िजला (District) Bhopal
वै किपक संपक सू (Alternate
मोबाइल नंबर (Mobile Number) 91 - 7898068165 9755664915
Contact No.) (Optional)
िपन कोड (Pin Code) 462030
थायी पता (Permanent Address)
INDRAVIHAR COLONY AIRPORT
पता (Premises No/ Name) A-138 थानीयता (Locality)
ROAD
उप-थानीयता (Sub-
NA दे श (Country) INDIA
Locality)(Optional):
राय (State) MADHYA PRADESH िजला (District) Bhopal
िपन कोड (Pin Code) 462030
यितगत योरा (PERSONAL DETAILS)
अयथी की जम ितिथ (Candidate's
अयथी का नाम (Candidate's Name) DAKSH LALWANI 09-12-2005
Date of Birth)
िपता / अिभभावक का नाम (Father / माता / अिभभावक का नाम (Mother /
MANOHAR LALWANI BHAWNA LALWANI
Guardian Name) 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 739102692723
Number)
PHOTOGRAPH
राय / केद शािसत दे श जहाँ से 12वीं /
समक उीण / उपिथत (State/ UT
MADHYA PRADESH े णी (Category ) GENERAL
from where 12th/ Equivalent Passed/
Appearing)
या आपको मधुमेह ह  (Are You िनवास की जगह ( Place of Residence
NO URBAN
Diabetic ? ) )
यिद आप एक Pwd उमीदवार ह , तो या
आपके पास ब चमाक िवकलांगता है (If you वािषक पािरवािरक आय ( Annual
NA 700001-800000
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
Others मायम ( Medium of schooling in English
)
qualifying exam )
परीा कद िववरण (Exam centre Details)
B. Planning, B.Arch., परीा के स के िलए आवे दन कर
के िलए आवे दन (Apply For) Session 1 & Session 2
B.E./B.Tech (Session Of Exam Apply For)
िपता / अिभभावक यवसाय (Father / GOVERNMENT िपता / अिभभावक योयता (Father /
Post Graduate
Guardian Occupation) SERVICE Guardian Qualification)
माता / अिभभावक यवसाय (Mother / माता / अिभभावक योयता (Mother /
Others POST GRADUATE
Guardian Occupation) Guardian Qualification)
परीा राय-पहला िवकप (Exam State परीा शहर-पहला िवकप (Exam City
MADHYA PRADESH BHOPAL
1st Choice ) 1st Choice )
परीा राय-दूसरा िवकप (Exam State परीा शहर-दूसरा िवकप (Exam City
MADHYA PRADESH INDORE
2nd Choice ) 2nd Choice )
परीा राय-तीसरा िवकप (Exam State परीा शहर-तीसरा िवकप (Exam
MADHYA PRADESH KHANDWA
3rd Choice ) City 3rd Choice )
परीा राय-चौथा िवकप (Exam State परीा शहर-चौथा िवकप (Exam City
MADHYA PRADESH UJJAIN
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 Urban
Schooling)
कू ल / कॉलेज का कार (Type of School / योयता परीा राय (Qualifying
Private Unaided MADHYA PRADESH
College) Examination State)
योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY
Bhopal कू ल बोड (School Board)
Examination District) EDUCATION
का 10वीं की माकशीट/माणप के
अनुसार िवालय/कॉलेज का नाम mithi gobindram pub sch कू ल / कॉलेज का पता (School /
bairagarh road, sant hirdaram nagar, bhopal
(School/College name should be as per sant hirdaram ngr bpl mp College Address)
Class 10th Mark sheet/certificate)
रोल नंबर 10वीं माणप के अनुसार
कू ल / कॉलेज िपनकोड (School / College
462030 (Roll number as per 10th 19109830
Pincode)
certificate)
पिरणाम मोड (Result Mode) Percentage पूणा क (Total Marks) 600.0
ातांक (Obtain Marks) 547.0 ितशत (Percentage) 91.17
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 Board of Secondary कू िलंग का थान (Place of
योयता परीा (Qualifying Exam) Urban
Education, New Delhi; Schooling)
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 MADHYA PRADESH
College) Examination State)
योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY
Bhopal 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 / govindpura sector ,bhel bhopal, madhya
gvn the global school
(School/College name should be as per College Address) pradesh
Class 12th Mark sheet/certificate)
रोल नंबर 12वीं माणप के अनुसार
कू ल / कॉलेज िपनकोड (School / College
462023 (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) 7024032312 ईमेल आईडी (Email ID) [email protected]
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) CPADHFVXY0
लेन-दे न की ितिथ (Date of
परीा शु क (Exam Fee) 4000.0 01-01-1900 00:00:00 AM
Transaction)
शु क जमा िकया गया (Fee Submitted
28-11-2023 01:06:50 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 : 49.43.40.129 Date of Downloading : 28-11-2023 01:10:53 AM