Joint Entrance Examination (Main) 2019

NATIONAL TESTING AGENCY

CONFIRMATION PAGE

Application No. 190310376302

DO NOT SEND THIS PAGE TO NATIONAL TESTING AGENCY(NTA).
CANDIDATES ARE REQUESTED TO RETAIN THE PRINTOUT OF CONFIRMATION PAGE FOR FUTURE REFERENCE.

Personal Details
Name: RAJEEV CHATURVEDI Date of Birth: 19/09/2002
Mother's Name: LALITA CHATURVEDI Category: GENERAL
Caste Name: NA Father's Name: N K CHATURVEDI
Person with Disability(PwD): NO State of Eligibility: MADHYA PRADESH
Percentage of Disability: -- Gender: MALE
Are you Diabetic: NO Nationality: INDIAN
Place of Residence: RURAL Do you need scribe: NO

Examination Details
Applying For: JEE(Main) Paper - 1 (B.E./B.Tech.) Only
Mode of Examination: COMPUTER BASED EXAMINATION Question Paper Medium: ENGLISH
1st Choice of Exam City: SAGAR 2nd Choice of Exam City: BHOPAL
3rd Choice of Exam City: JABALPUR 4th Choice of Exam City: INDORE

Academic Details
Year of passing class 10th: 2017 Place of 12th class schooling: CITY
Year of Passing or Appearing class 12th/Qualifying Exam: 2019 Type of Institution of Class 12th/Qualifying Exam: GOVERNMENT
School Board of class 12th/Qualifying Exam: CENTRAL BOARD OF SECONDARY EDUCATION
Name of the Qualifying Exam 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 Exam of --
Improvement Exam:
Name and Address of the School/College from where kendriy vidyalaya no.1 sagar cantt.10 mall road sagar
passed/appearing:

Candidate's Mailing Address

Country: India State: MADHYA PRADESH
District: SAGAR Address: anand nagar road no.3 makronia sagar
Locality: makronia City/Town/Village: sagar
Pin Code: 470004 Email Address: raj*******@gmail.com
Mobile Number: 789****388

Guardian Details
Qualification Occupation Annual Income
Father's/Guardian's: MATRICULATE GOVERNMENT SERVICE RS. 400001 -500000
Mother's: OTHERS OTHERS --

Payment Details
Provider Name: State Bank of India (MOPS) Payment Mode: Electronic Payment Gateway
Fee Type: Examination Fee Transaction Amount: 500 /-
Transaction ID: CPJ8162965 Date of Transaction: 14/09/2018 21:49:55
DECLARATION
I hereby declare that all the particulars stated in this application form are true to the best of my knowledge and belief.
Images Uploaded by Candidate
Candidate Photograph Candidate Signature