Joint Entrance Examination (Main) - 2018

CENTRAL BOARD OF SECONDARY EDUCATION

ACKNOWLEDGEMENT PAGE

Application No. 80068398

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Personal Details
Name: SAURABH SHARAN Date of Birth: 24/10/1999
Mother's Name: BABITA KUMARI Category GENERAL
Caste Name NA Father's Name: SHARVAN KUMAR
Person with Disability(PwD): NO State of Eligibility: UTTARAKHAND
Percentage of Disability: -- Gender: MALE
Are you Diabetic :: NO Nationality: INDIAN
Place of Residence: URBAN 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: DEHRADUN 2nd Choice of Exam Centre: DELHI
3rd Choice of Exam Centre: ROORKEE 4th Choice of Exam Centre: PATNA

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: CENTRAL BOARD OF SECONDARY EDUCATION
Name of the Qualifying Examination 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 Examination of
Improvement Examination:
Name and Address of the School/College from where The Indian Public School Mrityunjaydham P.O. Rajawala, Dehradun
passed/appearing:

Candidate's Mailing Address

Country: India State: BIHAR
District: PATNA Address: Mahabir Lane kannulal Road mithapur
Locality: Mithapur City/Town/Village: Patna
Pin Code: 800001 Email Address: sau*******@gmail.com
Mobile Number: 898****362

Guardian Details
Qualification Occupation Annual Income
Father's/Guardian's: GRADUATE GOVERNMENT SERVICE RS. 500001-600000
Mother's: -- -- --

Payment Details
Provider Name: Syndicate Bank Payment Gateway Payment Mode: Electronic Payment Gateway
Fee Type: Examination Fee Transaction Amount: 1000 /-
Transaction ID: LSM35859935090 Date of Transaction: 04-12-2017 16:06:38
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