सं युत वे श परीा (मु य)

Joint Entrance Examination (Main)

JEE(Main)
APPLICATION
240310787296
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) VISWARAJUVISWANATHARAO ईमेल पता (Email Address) [email protected]
NO 73 GROUND FLOOR, 4TH उप-थानीयता (Sub- SANJAY NAGAR BANGALORE
थानीयता (Locality)
CROSS Locality)(Optional) NORTH BANGALURU
दे श कोड (Country Code) +91 दे श (Country) INDIA
राय (State) KARNATAKA िजला (District) Bengaluru Urban
वै किपक संपक सू (Alternate
मोबाइल नंबर (Mobile Number) +91 - 9492330770 9703459936
Contact No.) (Optional)
िपन कोड (Pin Code) 560094
थायी पता (Permanent Address)
25-575-11-3, PARTHASARATHI
पता (Premises No/ Name) Y PHANI KUMAR थानीयता (Locality)
NAGAR
उप-थानीयता (Sub-
DHARMAVARAM दे श (Country) INDIA
Locality)(Optional):
राय (State) ANDHRA PRADESH िजला (District) Sri Sathya Sai
िपन कोड (Pin Code) 515671
यितगत योरा (PERSONAL DETAILS)
अयथी का नाम (Candidate's YAJAMANYAM NAGA ASHOK अयथी की जम ितिथ
24-08-2006
Name) KUMAR SASTRI (Candidate's Date of Birth)
िपता / अिभभावक का नाम (Father / माता / अिभभावक का नाम (Mother
Y PHANI KUMAR SASTRY Y VEENA
Guardian Name) / Guardian Name)
िलंग (Gender) MALE राटीयता (Nationality ) INDIAN
ANY OTHER VALID GOVT पहचान संया (Identification
पहचान के कार (Identity Type) 832370576542
IDENTITY WITH PHOTOGRAPH Number)
राय / केद शािसत दे श जहाँ से
12वीं / समक उीण / उपिथत
KARNATAKA े णी (Category ) GENERAL
(State/ UT 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
वािषक पािरवािरक आय ( Annual
है (If you are a Pwd Candidate, NA 0-100000
Family Income )
do you have benchmark
disability)?
योयता परीा म कू ली िशा का
तैयारी का तरीका ( Mode of
Tutorial Classes in School 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.E./B.Tech Session 1 & Session 2
(Session Of Exam Apply For)
िपता / अिभभावक यवसाय (Father िपता / अिभभावक योयता (Father
SELF-EMPLOYMENT Matriculate
/ Guardian Occupation) / Guardian Qualification)
माता / अिभभावक योयता
माता / अिभभावक यवसाय
Others (Mother / Guardian OTHERS
(Mother / Guardian Occupation)
Qualification)
परीा राय-पहला िवकप (Exam परीा शहर-पहला िवकप (Exam
KARNATAKA BENGALURU
State 1st Choice ) City 1st Choice )
परीा राय-दूसरा िवकप (Exam परीा शहर-दूसरा िवकप (Exam
KARNATAKA BENGALURU- URBAN
State 2nd Choice ) City 2nd Choice )
परीा राय-तीसरा िवकप (Exam परीा शहर-तीसरा िवकप (Exam
KARNATAKA CHIKABALLAPUR
State 3rd Choice ) City 3rd Choice )
परीा राय-चौथा िवकप (Exam परीा शहर-चौथा िवकप (Exam
KARNATAKA MYSURU(MYSORE)
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
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 Urban
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
Bengaluru Urban 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 /
(School/College name should be vidya nikethan public school ullal bangalore karnataka
College Address)
as per Class 10th Mark
sheet/certificate)
रोल नंबर 10वीं माणप के अनुसार
कू ल / कॉलेज िपनकोड (School /
45030 (Roll number as per 10th 18119342
College Pincode)
certificate)
पिरणाम मोड (Result Mode) Percentage पूणा क (Total Marks) 500.0
ातांक (Obtain Marks) 368.0 ितशत (Percentage) 73.60
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)
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) Urban
Board of Secondary Education, New Schooling)
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 KARNATAKA
School / College) Examination State)
योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY
Bengaluru Urban कू ल बोड (School Board)
Examination District) EDUCATION
का 12वीं की माकशीट/माणप के
अनुसार िवालय/कॉलेज का नाम
VIDYA NIKETHAN PUBLIC कू ल / कॉलेज का पता (School /
(School/College name should be ULLAL BANGALORE KARNATAKA
SCHOOL College Address)
as per Class 12th Mark
sheet/certificate)
रोल नंबर 12वीं माणप के अनुसार
कू ल / कॉलेज िपनकोड (School /
45030 (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
NO
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) 9440333290 ईमेल आईडी (Email ID) [email protected]
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) 880259
लेन-दे न की ितिथ (Date of
परीा शु क (Exam Fee) 2000.0 21-11-2023 21:17:41 PM
Transaction)
शु क जमा िकया गया (Fee
21-11-2023 21:16:53 PM
Submitted 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 : 157.48.113.66 Date of Downloading : 21-11-2023 21:18:02 PM