सं युत वे श परीा (मु य)

Joint Entrance Examination (Main)

JEE(Main)

APPLICATION NUMBER 240310971251

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)
AT NAYAGAON
पता (Premises No/ Name) ईमेल पता (Email Address) [email protected]
MANAS KUNJ MANDIR
उप-थानीयता (Sub-
थानीयता (Locality) PS EAST COLONY PO JAMALPUR
Locality)(Optional)
दे श कोड (Country Code) 91 दे श (Country) INDIA
राय (State) BIHAR िजला (District) Munger
वै किपक संपक सू (Alternate
मोबाइल नंबर (Mobile Number) 91 - 9661070899 7050437061
Contact No.) (Optional)
िपन कोड (Pin Code) 811214
थायी पता (Permanent Address)
AT NAYAGAON
पता (Premises No/ Name) थानीयता (Locality) PS EAST COLONY
MANAS KUNJ MANDIR
उप-थानीयता (Sub-
PO JAMALPUR दे श (Country) INDIA
Locality)(Optional):
राय (State) BIHAR िजला (District) Munger
िपन कोड (Pin Code) 811214
यितगत योरा (PERSONAL DETAILS)
अयथी की जम ितिथ (Candidate's
अयथी का नाम (Candidate's Name) SHASHWAT BHASKAR 26-05-2006
Date of Birth)
िपता / अिभभावक का नाम (Father / माता / अिभभावक का नाम (Mother /
ARBIND BHASKAR RACHNA KUMARI
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 361312520438
Number)
PHOTOGRAPH
राय / केद शािसत दे श जहाँ से 12वीं /
समक उीण / उपिथत (State/ UT
BIHAR े णी (Category ) OBC-(NCL) AS PER CENTRAL LIST
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 100001-200000
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
Online Coaching 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 /
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
BIHAR BHAGALPUR
State 1st Choice ) City 1st Choice )
परीा राय-दूसरा िवकप (Exam State परीा शहर-दूसरा िवकप (Exam
BIHAR PATNA
2nd Choice ) City 2nd Choice )
परीा राय-तीसरा िवकप (Exam परीा शहर-तीसरा िवकप (Exam
BIHAR PURNEA
State 3rd Choice ) City 3rd Choice )
परीा राय-चौथा िवकप (Exam State परीा शहर-चौथा िवकप (Exam
BIHAR MUZAFFARPUR
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 BIHAR
School / College) Examination State)
योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY
Munger कू ल बोड (School Board)
Examination District) EDUCATION
का 10वीं की माकशीट/माणप के DAV PUB SCH
अनुसार िवालय/कॉलेज का नाम NAYATOLA
कू ल / कॉलेज का पता (School / NAYATOLA KESHOPUR JAMALPUR
(School/College name should be as KESHOPUR
College Address) MUNGER
per Class 10th Mark JAMALPUR MUNGER
sheet/certificate) BR
रोल नंबर 10वीं माणप के अनुसार
कू ल / कॉलेज िपनकोड (School /
811214 (Roll number as per 10th 22171178
College Pincode)
certificate)
पिरणाम मोड (Result Mode) Percentage पूणा क (Total Marks) 500.0
ातांक (Obtain Marks) 419.0 ितशत (Percentage) 83.80
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 Rural
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 BIHAR
School / College) Examination State)
योयता परीा िजला (Qualifying CENTRAL BOARD OF SECONDARY
Munger कू ल बोड (School Board)
Examination District) EDUCATION
का 12वीं की माकशीट/माणप के
K N MEMO ACADEMY
अनुसार िवालय/कॉलेज का नाम
RAHMATPUR कू ल / कॉलेज का पता (School /
(School/College name should be as RAHMATPUR ASARGANJ MUNGER BR
ASARGANJ MUNGER College Address)
per Class 12th Mark
BR
sheet/certificate)
रोल नंबर 12वीं माणप के अनुसार
कू ल / कॉलेज िपनकोड (School /
813201 (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) 9934070899 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) 83900667928
लेन-दे न की ितिथ (Date of
परीा शु क (Exam Fee) 1800.0 24-11-2023 20:33:13 PM
Transaction)
शु क जमा िकया गया (Fee Submitted
24-11-2023 20:32:34 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 : 223.228.248.201 Date of Downloading : 24-11-2023 20:33:20 PM