Joint Entrance Examination (Main) - 2018

CENTRAL BOARD OF SECONDARY EDUCATION

ACKNOWLEDGEMENT PAGE

Application No. 80240985

DO NOT SEND THIS PAGE TO CBSE.
CANDIDATES ARE REQUESTED TO RETAIN THE PRINTOUT OF ACKNOWLEDGEMENT PAGE FOR FUTURE REFERENCE.

Personal Details
Name: AJAY Date of Birth: 03/02/1998
Mother's Name: USHA Category SC
Caste Name MAHAR Father's Name: GANESH
Person with Disability(PwD): NO State of Eligibility: MADHYA PRADESH
Percentage of Disability: -- Gender: MALE
Are you Diabetic :: NO Nationality: INDIAN
Place of Residence: RURAL You need scribe/reader ?: NO

Examination Details
Applying For: JEE(Main) Paper - 1 (B.E./B.Tech.) Only
Mode of Examination: PEN AND PAPER BASED EXAMINATION Question Paper Medium: HINDI
1st Choice of Exam Centre: BHOPAL 2nd Choice of Exam Centre: UJJAIN
3rd Choice of Exam Centre: INDORE 4th Choice of Exam Centre: JABALPUR

Academic Details
Year of passing class 10th: 2015 Place of 12th class schooling: CITY
Year of Passing or Appearing class 12th/Qualifying Exam: 2017 Type of Institution of Class 12th/Qualifying Exam: GOVERNMENT
School Board of class 12th/Qualifying Exam: MADHYA PRADESH BOARD OF SECONDARY EDUCATION
Name of the Qualifying Examination passed / appearing: Any Public School/ Board/ University examination in India or in any foreign country recognized as equivalent to
the 10+2 system by the Association of Indian Universities (AIU).
Percentage of Marks in Class 12th/Qualifying Exam: 83.2 Roll No. of Class 12th/Qualifying Exam: 276341326
Appeared/Appearing for Improvement of Class NO Mode of preperation: SELF STUDY
12th/Qualifying Exam:
Roll Number of Class 12th/Qualifying Examination of
Improvement Examination:
Name and Address of the School/College from where GOVERNMENT SHUBHASH SCHOOL FOR EXCELLENCE SHIVAJI NAGAR BHOPAL
passed/appearing:

Candidate's Mailing Address

Country: India State: MADHYA PRADESH
District: BURHANPUR Address: AMBEDKAR MOHALLA,WARD NO.3 SHEKHAPUR RAIYAT
Locality: VILLAGE POST SHEKHAPUR RAIYAT ,BURHANPUR City/Town/Village: VILLAGE POST SHEKHAPUR RAIYAT
Pin Code: 450332 Email Address: aja****com
Mobile Number: 895****963

Guardian Details
Qualification Occupation Annual Income
Father's/Guardian's: ILLITERATE AGRICULTURE UPTO 100000
Mother's: ILLITERATE OTHERS --

Payment Details
Provider Name: Syndicate Bank Payment Gateway Payment Mode: Electronic Payment Gateway
Fee Type: Examination Fee Transaction Amount: 500 /-
Transaction ID: LSM35874978773 Date of Transaction: 10-12-2017 12:24:17
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) - 2018. I shall abide by the terms and conditions thereon.

Images Uploaded by Candidate

Candidate Photograph Candidate Signature Parent/Guardian Signature