Joint Entrance Examination (Main) - 2018

CENTRAL BOARD OF SECONDARY EDUCATION

ACKNOWLEDGEMENT PAGE

Application No. 80249708

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

Personal Details
Name: NIKITA NISHCHAL Date of Birth: 17/05/2001
Mother's Name: SANGITA DEO Category GENERAL
Caste Name NA Father's Name: NAVIN KUMAR
Person with Disability(PwD): NO State of Eligibility: JHARKHAND
Percentage of Disability: -- Gender: FEMALE
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: BOKARO 2nd Choice of Exam Centre: DHANBAD
3rd Choice of Exam Centre: RANCHI 4th Choice of Exam Centre: PATNA

Academic Details
Year of passing class 10th: 2016 Place of 12th class schooling: CITY
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: 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: -- 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 DAV PUBLIC SCHOOL,SECTOR-4 SECTOR-4,BOKARO STEEL CITY,JHARKHAND
passed/appearing:

Candidate's Mailing Address

Country: India State: JHARKHAND
District: BOKARO Address: PLOT NO-H/C-4,CITY CENTRE,SECTOR-4
Locality: CITY CENTRE,SECTOR-4 City/Town/Village: BOKARO STEEL CITY
Pin Code: 827004 Email Address: nav****com
Mobile Number: 840****229

Guardian Details
Qualification Occupation Annual Income
Father's/Guardian's: GRADUATE PRIVATE SERVICE RS. 100001 -200000
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: 418685710 Date of Transaction: 10-12-2017 15:31:28
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