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): RICHARD RAJAN SOSAMMA RAJAN RAJAN DANIEL KERALA MALE INDIAN 563201486407

40021893
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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 ?:

12/02/1996 GENERAL NO -NO RURAL 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 ERNAKULAM KOZHIKODE Question Paper Medium: 2nd Choice of Exam Centre: 4th Choice of Exam Centre: ENGLISH THIRUVANTHAPURAM COIMBATORE

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

KERALA BOARD OF PUBLIC EXAMINATIONS Intermediate or two-year Pre-University examination conducted by a recognized Board/ University. -NO Roll Number of Class 12th/Qualifying Exam: Mode of preperation: -SELF STUDY

GOVERNMENT MODEL BOYS HIGHER SECONDARY SCHOOL HARIPAD

Candidate's Mailing Address

Address: City/Town/Village: State: Email Address: Land Line Number: CHIRAYIL HOUSE, THULAMPARAMBU SOUTH, HARIPAD Locality: PO HARIPAD KERALA crichardrajan@gmail.com 04792404911 District: Pin Code: Mobile Number: HARIPAD ALAPPUZHA 690514 9496602412

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

Payment Details
Payment Mode: Exam Fee: Deposit Date: Canara Bank e-Challan 1000 /19/11/2013 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. 8601911130001 NA --

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