Joint Entrance Examination (Main) 2019

NATIONAL TESTING AGENCY

CONFIRMATION PAGE

Application No. 190310433098

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Personal Details
Name: DEEP JITENDRA ADHIA Date of Birth: 19/08/2000
Mother's Name: VARSHABEN Category: GENERAL
Caste Name: NA Father's Name: JITENDRA
Person with Disability(PwD): NO State of Eligibility: GUJARAT
Percentage of Disability: -- Gender: MALE
Are you Diabetic: NO Nationality: INDIAN
Place of Residence: URBAN Do you need scribe: 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
COMPUTER BASED EXAMINATION Question Paper Medium: ENGLISH
VALSAD 2nd Choice of Exam Centre: THANE
MUMBAI/MUMBAI SUBURBAN 4th Choice of Exam Centre: SURAT

Academic Details
Year of passing class 10th: 2017 Place of 12th class schooling: TOWN
Year of Passing or Appearing class 12th/Qualifying Exam: 2019 Type of Institution of Class 12th/Qualifying Exam: PRIVATE
School Board of class 12th/Qualifying Exam: CBSE i (CBSE international)
Name of the Qualifying Exam 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: -- 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 Exam of --
Improvement Exam:
Name and Address of the School/College from where vallabh asharam international school NH.NO-08,KILLA PARDI
passed/appearing:

Candidate's Mailing Address

Country: India State: GUJARAT
District: VALSAD Address: vipul park co-op-hsg,society behind fennel factory
Locality: killa pardi City/Town/Village: Valsad
Pin Code: 396125 Email Address: adh*******@gmail.com
Mobile Number: 942****558

Guardian Details
Qualification Occupation Annual Income
Father's/Guardian's: MATRICULATE SELF EMPLOYMENT RS. 200001 - 300000
Mother's: GRADUATE SELF EMPLOYMENT UPTO 100000

Payment Details
Provider Name: State Bank of India (MOPS) Payment Mode: Electronic Payment Gateway
Fee Type: Examination Fee Transaction Amount: 500 /-
Transaction ID: CPJ8599419 Date of Transaction: 16/09/2018 20:44:24
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) - 2019. I shall abide by the terms and conditions thereon.

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