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): RAJAT GUPTA MEENA GUPTA RAMNARAYAN GUPTA UTTAR PRADESH MALE INDIAN --

40586560
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Date of Birth: Category Person with Disability(PwD): Percentage of Disability: Are you the only child?: Place of Residence: You need scribe/reader ?:

17/08/1996 GENERAL NO -NO RURAL 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 JHANSI KANPUR Question Paper Medium: 2nd Choice of Exam Centre: 4th Choice of Exam Centre: ENGLISH GWALIOR AGRA

Academic Details
Year of passing class 10th: School Board of class 12th/Qualifying Exam: Name of the Qualifying Examination passed / appearing: 2012 Place of 12th class schooling: Type of Institution of Class 12th/Qualifying Exam: VILLAGE PRIVATE Year of Passing or Appearing class 12th/Qualifying Exam: 2014

CENTRAL BOARD OF SECONDARY EDUCATION The final examination of the 10+2 system, conducted by any recognized central/ state Board, such as Central Board of Secondary Education, New Delhi; Council for the Indian School Certificate Examinations, New Delhi; etc. -NO Roll Number of Class 12th/Qualifying Exam: Mode of preperation: -SELF STUDY

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:

JAI ACADEMY SHIVPURI ROAD, JHANSI

Candidate's Mailing Address

Address: City/Town/Village: State: Email Address: Land Line Number: 15 CHANDRASHEKHAR AZAD ROAD JHANSI UTTAR PRADESH rajkumar.w93@gmail.com -Locality: District: Pin Code: Mobile Number: KOTWALI KI DHAL JHANSI 284002 8004920005

Guardian Details
Qualification Father's/Guardian's: Mother's: ILLITERATE MATRICULATE Occupation BUSINESS OTHERS (INCLUDING HOUSE WIFE) Annual Income UPTO 100000 --

Payment Details
Payment Mode: Exam Fee: Card Type: Credit / Debit Card 1000 /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. MSPD3183363464 03-12-2013 18:18:10 --

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