Joint Entrance Examination (Main) - 2018

CENTRAL BOARD OF SECONDARY EDUCATION

ACKNOWLEDGEMENT PAGE

Application No. 80656254

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

Personal Details
Name: AMPIKA SONI Date of Birth: 28/10/2000
Mother's Name: SRIDEVI LISA Category OBC- NCL (CENTRAL LIST)
Caste Name Kammalar Father's Name: MURALIDHARAN T
Person with Disability(PwD): NO State of Eligibility: TAMIL NADU
Percentage of Disability: -- Gender: FEMALE
Are you Diabetic :: NO Nationality: INDIAN
Place of Residence: URBAN You need scribe/reader ?: 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 Question Paper Medium: ENGLISH
COIMBATORE 2nd Choice of Exam Centre: KOZHIKODE
MADURAI 4th Choice of Exam Centre: THIRUVANANTHAPURAM

Academic Details
Year of passing class 10th: 2016 Place of 12th class schooling: TOWN
Year of Passing or Appearing class 12th/Qualifying Exam: 2018 Type of Institution of Class 12th/Qualifying Exam: PRIVATE
School Board of class 12th/Qualifying Exam: TAMIL NADU BOARD OF HIGHER 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: -- Roll No. of Class 12th/Qualifying Exam: --
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 Ideal Matric. Higher Secondary School Ideal Matric. Higher Secondary School, Gudalur, The Nilgiris - 643212.
passed/appearing:

Candidate's Mailing Address

Country: India State: TAMIL NADU
District: NILGIRIS Address: 4 / 339, Rajagopalapuram, Gudalur.
Locality: Rajagopalapuram City/Town/Village: Gudalur
Pin Code: 643211 Email Address: amp****com
Mobile Number: 763****191

Guardian Details
Qualification Occupation Annual Income
Father's/Guardian's: GRADUATE LAW PRACTICE UPTO 100000
Mother's: MATRICULATE OTHERS UPTO 100000

Payment Details
Provider Name: ICICI Bank Payment Mode: Electronic Payment Gateway
Fee Type: Examination Fee Transaction Amount: 500 /-
Transaction ID: 426962481 Date of Transaction: 24-12-2017 12:53:49
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