Joint Entrance Examination (Main) - 2018

CENTRAL BOARD OF SECONDARY EDUCATION

ACKNOWLEDGEMENT PAGE

Application No. 80427491

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

Personal Details
Name: ANKIT AGRAWAL Date of Birth: 14/05/2000
Mother's Name: SAPANA AGRAWAL Category GENERAL
Caste Name NA Father's Name: DILIP KUMAR AGRAWAL
Person with Disability(PwD): NO State of Eligibility: MADHYA PRADESH
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: PEN AND PAPER BASED EXAMINATION Question Paper Medium: ENGLISH
1st Choice of Exam Centre: GWALIOR 2nd Choice of Exam Centre: JHANSI
3rd Choice of Exam Centre: AGRA 4th Choice of Exam Centre: DELHI

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: 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: -- Roll No. of Class 12th/Qualifying Exam: --
Appeared/Appearing for Improvement of Class NO Mode of preperation: COACHING
12th/Qualifying Exam:
Roll Number of Class 12th/Qualifying Examination of
Improvement Examination:
Name and Address of the School/College from where Vasudeo English Medium Higher Secondary School Nazar Bagh, Datia , M.P 475661
passed/appearing:

Candidate's Mailing Address

Country: India State: MADHYA PRADESH
District: DATIA Address: 313, Dall Mill
Locality: KunjanPura City/Town/Village: Datia
Pin Code: 475661 Email Address: ank****com
Mobile Number: 756****790

Guardian Details
Qualification Occupation Annual Income
Father's/Guardian's: GRADUATE BUSINESS RS. 300001 -400000
Mother's: GRADUATE OTHERS UPTO 100000

Payment Details
Provider Name: ICICI Bank Payment Mode: Electronic Payment Gateway
Fee Type: Examination Fee Transaction Amount: 1000 /-
Transaction ID: 421118328 Date of Transaction: 14-12-2017 22:50:18
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