Joint Entrance Examination (Main) - 2014 CENTRAL BOARD OF SECONDARY EDUCATION ACKNOWLEDGEMENT PAGE

Application No.
Personal Details
Name: Mother's Name: Father's Name: State of Eligibility: Gender: Nationality: Aadhaar Number (UIDAI): JHA GAUTAM VIJAY RANJANA RANJANA JHA VIJAY JHA MAHARASTRA MALE INDIAN --

40237140
DO NOT SEND THIS PAGE TO CBSE.

CANDIDATES ARE REQUESTED TO RETAIN THE PRINTOUT OF ACKNOWLEDGEMENT PAGE FOR FUTURE REFERENCE.

Date of Birth: Category Person with Disability(PwD): Percentage of Disability: Are you the only child?: Place of Residence: You need scribe/reader ?:

16/04/1997 GENERAL NO -NO URBAN NO

Examination Details
Applying For: Mode of Examination: 1st Choice of Exam Centre: 3rd Choice of Exam Centre: JEE(Main) Paper - 1 (B.E./B.Tech.) Only PEN AND PAPER BASED EXAMINATION THANE NAVI MUMBAI Question Paper Medium: 2nd Choice of Exam Centre: 4th Choice of Exam Centre: ENGLISH MUMBAI PUNE

Academic Details
Year of passing class 10th: School Board of class 12th/Qualifying Exam: Name of the Qualifying Examination passed / appearing: Percentage of Marks in Class 12th/Qualifying Exam: Appearing for Improvement of Class 12th/Qualifying Exam: Name and Address of the School/College from where passed / appearing: 2012 Place of 12th class schooling: Type of Institution of Class 12th/Qualifying Exam: TOWN PRIVATE Year of Passing or Appearing class 12th/Qualifying Exam: 2014

MAHARASTRA STATE BOARD OF SECONDARY AND HIGHER SECONDARY EDUCATION Intermediate or two-year Pre-University examination conducted by a recognized Board/ University. -NO Roll Number of Class 12th/Qualifying Exam: Mode of preperation: -COACHING

S.D.T KALANI COLLEGE A BLOCK,NEAR SHAHAD RLY. STN, ULHASNAGAR 421001

Candidate's Mailing Address

Address: City/Town/Village: State: Email Address: Land Line Number: A/12, A BLOCK ROAD, BALKRISHNA NAGAR, MASTER CHAWL ULHASNAGAR MAHARASTRA jhagautam164@gmail.com -Locality: District: Pin Code: Mobile Number: OPP. SAI BABA TEMPLE THANE 421001 9930607351

Guardian Details
Qualification Father's/Guardian's: Mother's: GRADUATE -Occupation PRIVATE SERVICE -Annual Income RS. 100001 -200000 --

Payment Details
Payment Mode: Exam Fee: Deposit Date: ICICI Bank e-Challan 1000 /27/11/2013 Transaction ID: Branch Name/Code: -DECLARATION I hereby declare that all the particulars stated in this application form are true to the best of my knowledge and belief. I have read and understood the JEE procedures for both JEE(Main) and JEE(Advanced) - 2014. I shall abide by the terms and conditions thereon. M375331 NA --

Images Uploaded by Candidate Photograph Signature Thumb Impression