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): DIVYA KUMARI TARUN BALA JUGAL KISHORE HARYANA FEMALE INDIAN 304805666037

41232500
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 ?:

04/08/1996 GENERAL NO -NO URBAN NO

Examination Details
Applying For: Examination Mode (B.Tech.): Question Paper Medium: 2nd Choice of Exam Centre: 4th Choice of Exam Centre: JEE(Main) Paper - 1 and Paper - 2 Both PEN AND PAPER BASED EXAMINATION ENGLISH DELHI/NEW DELHI (NCR) AGRA Examination Mode (B.Arch.): 1st Choice of Exam Centre: 3rd Choice of Exam Centre: PEN AND PAPER BASED EXAMINATION FARIDABAD BAREILLY

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: CITY GOVERNMENT Year of Passing or Appearing class 12th/Qualifying Exam: 2014

HARYANA BOARD OF EDUCATION 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). -NO Roll Number of Class 12th/Qualifying Exam: Mode of preperation: -SELF STUDY

GOVT GIRLS SR SEC SCHOOL NIT FARIDABAD NEAR AUDITORIUM MCF NIT FARIDABAD 121001

Candidate's Mailing Address

Address: City/Town/Village: State: Email Address: Land Line Number: HOUSE NO B-173 DABUA COLONY FARIDABAD FARIDABAD HARYANA sehgal.dinesh25@gmail.com -Locality: District: Pin Code: Mobile Number: DABUA COLONY NIT FARIDABAD 121001 9999246083

Guardian Details
Qualification Father's/Guardian's: Mother's: MATRICULATE GRADUATE Occupation PRIVATE SERVICE TEACHING / RESEARCH Annual Income RS. 100001 -200000 UPTO 100000

Payment Details
Payment Mode: Exam Fee: Card Type: Credit / Debit Card 900 /VISA/Master Card Transaction ID: Date of Transaction: -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. MSPD3202235327 22-12-2013 16:40:20 --

Images Uploaded by Candidate Photograph Signature Thumb Impression