Joint Entrance Examination (Main) 2019

NATIONAL TESTING AGENCY

CONFIRMATION PAGE

Application No. 190310894881

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Personal Details
Name: NISHA SHARMA Date of Birth: 09/04/2002
Mother's Name: ANJU SHARMA Category: GENERAL
Caste Name: NA Father's Name: KHICHENDRA KUMAR SHARMA
Person with Disability(PwD): NO State of Eligibility: CHHATTISGARH
Percentage of Disability: -- Gender: FEMALE
Are you Diabetic: NO Nationality: INDIAN
Place of Residence: URBAN Do you need scribe: NO

Examination Details
Applying For: JEE(Main) Paper - 1 (B.E./B.Tech.) Only
Mode of Examination: COMPUTER BASED EXAMINATION Question Paper Medium: ENGLISH
1st Choice of Exam Centre: RAIPUR 2nd Choice of Exam Centre: BHILAI/DURG
3rd Choice of Exam Centre: BILASPUR 4th Choice of Exam Centre: JABALPUR

Academic Details
Year of passing class 10th: 2017 Place of 12th class schooling: CITY
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: CHATTISGARH MADHYAMIK SHIKSHA MANDAL (CHATTISGARH BOARD OF SECONDARY EDUCATION)
Name of the Qualifying Exam 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: OTHERS
12th/Qualifying Exam:
Roll Number of Class 12th/Qualifying Exam of --
Improvement Exam:
Name and Address of the School/College from where HOLY MOTHERS HR SEC PUBLIC SCHOOL RAIPUR CG SUNDER NAGAR RAIPUR CG
passed/appearing:

Candidate's Mailing Address

Country: India State: CHHATTISGARH
District: RAIPUR Address: BANJARI NAGAR KUSHALPUR RAIPUR CG
Locality: SUNDER NAGAR City/Town/Village: RAIPUR
Pin Code: 492001 Email Address: nis*******@gmail.com
Mobile Number: 916****181

Guardian Details
Qualification Occupation Annual Income
Father's/Guardian's: MATRICULATE PRIVATE SERVICE RS. 100001 -200000
Mother's: GRADUATE -- --

Payment Details
Provider Name: State Bank of India (MOPS) Payment Mode: Electronic Payment Gateway
Fee Type: Examination Fee Transaction Amount: 250 /-
Transaction ID: CPK2040743 Date of Transaction: 29/09/2018 19:51:20
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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