Joint Entrance Examination (Main) 2019

NATIONAL TESTING AGENCY

CONFIRMATION PAGE

Application No. 190310796610

DO NOT SEND THIS PAGE TO NATIONAL TESTING AGENCY(NTA).
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Personal Details
Name: OM KAMLESHBHAI PATEL Date of Birth: 10/05/2002
Mother's Name: VANDANABEN KAMLESHBHAI PATEL Category: GENERAL
Caste Name: NA Father's Name: KAMLESHBHAI HARSHADBHAI
PATEL
Person with Disability(PwD): NO State of Eligibility: GUJARAT
Percentage of Disability: -- Gender: MALE
Are you Diabetic: NO Nationality: INDIAN
Place of Residence: RURAL 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: GUJARATI
1st Choice of Exam City: SURAT 2nd Choice of Exam City: VADODARA
3rd Choice of Exam City: AHMEDABAD 4th Choice of Exam City: ANAND

Academic Details
Year of passing class 10th: 2017 Place of 12th class schooling: VILLAGE
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: GUJARAT SECONDARY EDUCATION BOARD
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 Shree maharaj K.G.M school BHAKTI PARK
passed/appearing:

Candidate's Mailing Address

Country: India State: GUJARAT
District: BHARUCH Address: 7 jashupatel park zadeshwar road bharuch
Locality: KGM school City/Town/Village: BHARUCH
Pin Code: 392011 Email Address: kam*******@gmail.com
Mobile Number: 997****744

Guardian Details
Qualification Occupation Annual Income
Father's/Guardian's: -- -- --
Mother's: -- -- --

Payment Details
Provider Name: State Bank of India (MOPS) Payment Mode: Electronic Payment Gateway
Fee Type: Examination Fee Transaction Amount: 500 /-
Transaction ID: CPK1324018 Date of Transaction: 27/09/2018 21:31:12
DECLARATION
I hereby declare that all the particulars stated in this application form are true to the best of my knowledge and belief.

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