सं युत वे श परीा (मु य)

Joint Entrance Examination (Main)

JEE(Main)

APPLICATION NUMBER 240311307810

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यितगत योरा (Contact Details) वतमान पता (Present Address)
H NO 622 GOUSHALA
पता (Premises No/ Name) ईमेल पता (Email Address) [email protected]
MOHALLA
थानीयता (Locality) SIRSA उप-थानीयता (Sub-Locality)(Optional) SIRSA
दे श कोड (Country Code) 91 दे श (Country) INDIA
राय (State) HARYANA िजला (District) Sirsa
वै किपक संपक सू (Alternate Contact
मोबाइल नंबर (Mobile Number) 91 - 9802470273 9306878562
No.) (Optional)
िपन कोड (Pin Code) 125055
थायी पता (Permanent Address)
H NO 622 GOUSHALA
पता (Premises No/ Name) थानीयता (Locality) SIRSA
MOHALLA
उप-थानीयता (Sub-
SIRSA दे श (Country) INDIA
Locality)(Optional):
राय (State) HARYANA िजला (District) Sirsa
िपन कोड (Pin Code) 125055
यितगत योरा (PERSONAL DETAILS)
अयथी की जम ितिथ (Candidate's Date
अयथी का नाम (Candidate's Name) MUNISH 11-11-2005
of Birth)
िपता / अिभभावक का नाम (Father / माता / अिभभावक का नाम (Mother /
SANT LAL BHANWARI
Guardian Name) Guardian Name)
िलंग (Gender) MALE राटीयता (Nationality ) INDIAN
ANY OTHER VALID
पहचान के कार (Identity Type) GOVT IDENTITY WITH पहचान संया (Identification Number) 872477155277
PHOTOGRAPH
राय / केद शािसत दे श जहाँ से 12वीं /
समक उीण / उपिथत (State/ UT
HARYANA े णी (Category ) GENERAL
from where 12th/ Equivalent Passed/
Appearing)
या आपको मधुमेह ह  (Are You
NO िनवास की जगह ( Place of Residence ) URBAN
Diabetic ? )
यिद आप एक Pwd उमीदवार ह , तो या
आपके पास ब चमाक िवकलांगता है (If you वािषक पािरवािरक आय ( Annual Family
NA 0-100000
are a Pwd Candidate, do you have Income )
benchmark disability)?
योयता परीा म कू ली िशा का मायम (
तैयारी का तरीका ( Mode of Preparation ) Self-Study Medium of schooling in qualifying English
exam )
परीा कद िववरण (Exam centre Details)
परीा 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 योयता (Father /
AGRICULTURE 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 1st
HARYANA HISAR
1st Choice ) Choice )
परीा राय-दूसरा िवकप (Exam State परीा शहर-दूसरा िवकप (Exam City 2nd
PUNJAB BHATINDA
2nd Choice ) Choice )
परीा राय-तीसरा िवकप (Exam State परीा शहर-तीसरा िवकप (Exam City 3rd
DELHI DELHI/NEW DELHI
3rd Choice ) Choice )
परीा राय-चौथा िवकप (Exam State परीा शहर-चौथा िवकप (Exam City 4th
UTTAR PRADESH GHAZIABAD
4th Choice ) 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 / Jawahar Navodaya योयता परीा राय (Qualifying
HARYANA
College) Vidyalaya (JNVs) Examination State)
योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY
Sirsa कू ल बोड (School Board)
Examination District) EDUCATION
का 10वीं की माकशीट/माणप के
अनुसार िवालय/कॉलेज का नाम jawahar navodaya कू ल / कॉलेज का पता (School / College
odhan sirsa pin 125077
(School/College name should be as per vidyalaya sirsa odhan Address)
Class 10th Mark sheet/certificate)
कू ल / कॉलेज िपनकोड (School / College रोल नंबर 10वीं माणप के अनुसार (Roll
125077 17228418
Pincode) number as per 10th certificate)
पिरणाम मोड (Result Mode) Percentage पूणा क (Total Marks) 500.0
ातांक (Obtain Marks) 439.0 ितशत (Percentage) 87.80
th
12वीं या समक योयता िववरण (12 or equivalent Qualification Details)
उीण / सिमिलत होने का वष (Year of
उीण 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 Board of Secondary
योयता परीा (Qualifying Exam) 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 / Jawahar Navodaya योयता परीा राय (Qualifying
HARYANA
College) Vidyalaya (JNVs) Examination State)
योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY
Sirsa कू ल बोड (School Board)
Examination District) EDUCATION
का 12वीं की माकशीट/माणप के
अनुसार िवालय/कॉलेज का नाम jawahar navodaya odhan कू ल / कॉलेज का पता (School / College
odhan sirsa
(School/College name should be as per sirsa Address)
Class 12th Mark sheet/certificate)
कू ल / कॉलेज िपनकोड (School / College रोल नंबर 12वीं माणप के अनुसार (Roll
125077 NA
Pincode) number as per 12th 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) 7206830717 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) 175543982
परीा शु क (Exam Fee) 1000.0 लेन-दे न की ितिथ (Date of Transaction) 30-11-2023 10:42:49 AM
शु क जमा िकया गया (Fee Submitted
30-11-2023 10:42:13 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 : 103.183.35.1 Date of Downloading : 30-11-2023 10:44:18 AM