Joint Entrance Examination (Main) - 2018

CENTRAL BOARD OF SECONDARY EDUCATION

ACKNOWLEDGEMENT PAGE

Application No. 80808956

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

Personal Details
Name: SOMBIR Date of Birth: 05/12/1999
Mother's Name: SHUNKATLA Category OBC- NCL (CENTRAL LIST)
Caste Name AHIR Father's Name: RAMBIR
Person with Disability(PwD): NO State of Eligibility: HARYANA
Percentage of Disability: -- Gender: MALE
Are you Diabetic :: NO Nationality: INDIAN
Place of Residence: RURAL You need scribe/reader ?: NO

Examination Details
Applying For: JEE(Main) Paper - 1 (B.E./B.Tech.) Only
Mode of Examination: COMPUTER BASED EXAMINATION Question Paper Medium: ENGLISH
Choice of Online Exam Centre: GURUGRAM

Academic Details
Year of passing class 10th: 2016 Place of 12th class schooling: VILLAGE
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: BOARD OF SCHOOL EDUCATION HARYANA (HARYANA BOARD OF 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 C.R.M. Sr. Sec. School ROJHUWAS
passed/appearing:

Candidate's Mailing Address

Country: India State: HARYANA
District: REWARI Address: MOHDINPUR
Locality: REWARI City/Town/Village: MOHDINPUR
Pin Code: 123401 Email Address: tej****com
Mobile Number: 750****406

Guardian Details
Qualification Occupation Annual Income
Father's/Guardian's: ILLITERATE AGRICULTURE UPTO 100000
Mother's: ILLITERATE AGRICULTURE UPTO 100000

Payment Details
Provider Name: ICICI Bank Payment Mode: Electronic Payment Gateway
Fee Type: Examination Fee Transaction Amount: 500 /-
Transaction ID: 427315849 Date of Transaction: 25-12-2017 06:53:32

Selected Date for Computer Based Examination of Paper-1

Your selected date for Computer Based Examination: No date is selected.
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