Joint Entrance Examination (Main) - 2018

CENTRAL BOARD OF SECONDARY EDUCATION

ACKNOWLEDGEMENT PAGE

Application No. 80720132

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

Personal Details
Name: ABUTALHA ANSARI Date of Birth: 25/08/1999
Mother's Name: MADINA KHATUN ANSARI Category OBC- NCL (CENTRAL LIST)
Caste Name ansari Father's Name: ABDUL QAYUM ANSARI
Person with Disability(PwD): NO State of Eligibility: DELHI
Percentage of Disability: -- Gender: MALE
Are you Diabetic :: NO Nationality: INDIAN
Place of Residence: URBAN You need scribe/reader ?: NO

Examination Details
Applying For: JEE(Main) Paper - 1 (B.E./B.Tech.) Only
Mode of Examination: COMPUTER BASED EXAMINATION Question Paper Medium: ENGLISH
Choice of Online Exam Centre: DELHI

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: CENTRAL BOARD OF SECONDARY EDUCATION
Name of the Qualifying Examination passed / appearing: 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.
Percentage of Marks in Class 12th/Qualifying Exam: 60 Roll No. of Class 12th/Qualifying Exam: 9699084
Appeared/Appearing for Improvement of Class YES 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 GOVT BOYS SR SEC SCHOOL A-BLOCK GOVT BOYS SR SEC SCHOOL
passed/appearing:

Candidate's Mailing Address

Country: India State: DELHI
District: WEST DELHI Address: D-1/7 MANSA RAM PARK UTTAM NAGAR
Locality: DELHI City/Town/Village: NEW DELHI
Pin Code: 110059 Email Address: asa****com
Mobile Number: 704****483

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

Payment Details
Provider Name: ICICI Bank Payment Mode: Electronic Payment Gateway
Fee Type: Examination Fee Transaction Amount: 500 /-
Transaction ID: 425972353 Date of Transaction: 22-12-2017 19:21:11

Selected Date for Computer Based Examination of Paper-1

Your selected date for Computer Based Examination: No date is selected.
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.

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Candidate Photograph Candidate Signature Parent/Guardian Signature