Joint Entrance Examination (Main) - 2014 CENTRAL BOARD OF SECONDARY EDUCATION ACKNOWLEDGEMENT PAGE

Application No.
Personal Details
Name: Mother's Name: Father's Name: State of Eligibility: Gender: Nationality: Aadhaar Number (UIDAI): VANDITA GUPTA KIRAN GUPTA D.P. GUPTA HARYANA FEMALE INDIAN --

40020493
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Date of Birth: Category Person with Disability(PwD): Percentage of Disability: Are you the only child?: Place of Residence: You need scribe/reader ?:

08/10/1997 GENERAL NO -NO URBAN 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 PEN AND PAPER BASED EXAMINATION FARIDABAD GURGAON Question Paper Medium: 2nd Choice of Exam Centre: 4th Choice of Exam Centre: ENGLISH DELHI/NEW DELHI (NCR) KARNAL

Academic Details
Year of passing class 10th: School Board of class 12th/Qualifying Exam: Name of the Qualifying Examination passed / appearing: 2012 Place of 12th class schooling: Type of Institution of Class 12th/Qualifying Exam: CITY PRIVATE Year of Passing or Appearing class 12th/Qualifying Exam: 2014

CENTRAL BOARD OF SECONDARY EDUCATION 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. -NO Roll Number of Class 12th/Qualifying Exam: Mode of preperation: -SELF STUDY

Percentage of Marks in Class 12th/Qualifying Exam: Appearing for Improvement of Class 12th/Qualifying Exam: Name and Address of the School/College from where passed / appearing:

K.L.mehta dayanand public school sector-16,faridabad

Candidate's Mailing Address

Address: City/Town/Village: State: Email Address: Land Line Number: House no-581,Sector-16,Faridabad faridabad HARYANA sgheights333@gmail.com 01292221177 Locality: District: Pin Code: Mobile Number: sector-16 faridabad 121002 9654544581

Guardian Details
Qualification Father's/Guardian's: Mother's: POST GRADUATE MATRICULATE Occupation OTHERS (INCLUDING HOUSE WIFE) OTHERS (INCLUDING HOUSE WIFE) Annual Income RS. 200001 - 300000 UPTO 100000

Payment Details
Payment Mode: Exam Fee: Deposit Date: ICICI Bank e-Challan 500 /18/11/2013 Transaction ID: Branch Name/Code: -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) - 2014. I shall abide by the terms and conditions thereon. M399968 NA --

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