Personal Details
Name: REVANTH JAI SARAN SELVAM Date of Birth: 05/12/1999
Mother's Name: NAGAJOTHI Category OBC- NCL (CENTRAL LIST)
Father's Name: SELVAM Person with Disability(PwD): NO
State of Eligibility: TAMIL NADU Percentage of Disability: --
Gender: MALE In case of girl candidate, Are NO
you the only child of your
parents?:
Nationality: INDIAN Place of Residence: RURAL
Aadhaar Number 480890124419 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: MADURAI 2nd Choice of Exam Centre: COIMBATORE
3rd Choice of Exam Centre: CHENNAI 4th Choice of Exam Centre: BENGALURU
Academic Details
Year of passing class 10th: 2015 Place of 12th class schooling: VILLAGE
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: TAMIL NADU BOARD OF HIGHER SECONDARY EDUCATION
Name of the Qualifying Examination 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: SELF STUDY
12th/Qualifying Exam:
Roll Number of Class 12th/Qualifying Examination of
Improvement Examination:
Name and Address of the School/College from where SAMABHARATHAM MATRIC HR.SEC.SCHOOL KILANGULAM PERAIYUR TALUKA MADURAI DIST-625703
passed/appearing:
Guardian Details
Qualification Occupation Annual Income
Father's/Guardian's: GRADUATE PRIVATE SERVICE RS. 200001 - 300000
Mother's: GRADUATE GOVERNMENT SERVICE RS. 300001 -400000
Payment Details
Provider Name: HDFC Bank Payment Gateway Payment Mode: Electronic Payment Gateway
Fee Type: Examination Fee Transaction Amount: 1000 /-
Transaction ID: HHMP5023653322 Date of Transaction: 04-01-2017 19:26:52
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.