Joint Entrance Examination (Main) - 2017

CENTRAL BOARD OF SECONDARY EDUCATION

ACKNOWLEDGEMENT PAGE

Application No. 70544021

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

Personal Details
Name: RAVINDER Date of Birth: 29/11/1999
Mother's Name: PREM LATA Category OBC- NCL (CENTRAL LIST)
Father's Name: RAJE RAM Person with Disability(PwD): NO
State of Eligibility: HARYANA Percentage of Disability: --
Gender: MALE Are you the only child?: NO
Nationality: INDIAN Place of Residence: RURAL
Aadhaar Number 485686727593 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: HISAR 2nd Choice of Exam Centre: KURUKSHETRA
3rd Choice of Exam Centre: KARNAL 4th Choice of Exam Centre: GURGAON

Academic Details
Year of passing class 10th: 2015 Place of 12th class schooling: TOWN
Year of Passing or Appearing class 12th/Qualifying Exam: 2017 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 ADARSH SR SEC SCHOOL SIWANI, BHIWANI
passed/appearing:

Candidate's Mailing Address

Country: India State: HARYANA
District: HISSAR Address: VPO SALEMGARH
Locality: HISAR City/Town/Village: HISAR
Pin Code: 125052 Email Address: ravisain231@gmail.com
Mobile Number: 9813441542 Land Line Number: --

Guardian Details
Qualification Occupation Annual Income
Father's/Guardian's: MATRICULATE AGRICULTURE UPTO 100000
Mother's: MATRICULATE OTHERS (INCLUDING HOUSE WIFE) --

Payment Details
Provider Name: Syndicate Bank Payment Gateway Payment Mode: Electronic Payment Gateway
Fee Type: Examination Fee Transaction Amount: 1000 /-
Transaction ID: HHMP4986288734 Date of Transaction: 20-12-2016 16:55:38
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) - 2017. I shall abide by the terms and conditions thereon.

Images Uploaded by Candidate

Photograph Signature

Ravinder123@