Joint Entrance Examination (Main) - 2015

CENTRAL BOARD OF SECONDARY EDUCATION

ACKNOWLEDGEMENT PAGE

Application No.

50202593
DO NOT SEND THIS PAGE TO CBSE.

CANDIDATES ARE REQUESTED TO RETAIN THE PRINTOUT OF ACKNOWLEDGEMENT PAGE FOR FUTURE REFERENCE.

Personal Details
Name:

ABHISHEK SRIVASTAVA

Date of Birth:

12/04/1997

Mother's Name:

NEELAM SRIVASTAVA

Category

GENERAL

Father's Name:

ARVIND KUMAR SRIVASTAVA

Person with Disability(PwD):

NO

State of Eligibility:

UTTAR PRADESH

Percentage of Disability:

--

Gender:

MALE

Are you the only child?:

NO

Nationality:

INDIAN

Place of Residence:

URBAN

Aadhaar Number (UIDAI):

--

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:

DELHI/NEW DELHI (NCR)

2nd Choice of Exam Centre:

GORAKHPUR

3rd Choice of Exam Centre:

LUCKNOW

4th Choice of Exam Centre:

BAREILLY

Academic Details
Year of passing class 10th:

2013

Year of Passing or Appearing class 12th/Qualifying Exam: 2015

Place of 12th class schooling:

CITY

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

12th/Qualifying Exam:

NO

Mode of preperation:

SELF STUDY

Roll Number of Class 12th/Qualifying Examination of

Improvement Examination:
Name and Address of the School/College from where
passed/appearing:

DAV PUBLIC SCHOOL RAJENDER NAGAR, SAHIBABAD, GHAZIABAD, UTTAR PRADESH

Candidate's Mailing Address

Address:

FLAT NO-B/3, PLOT NO 97, OM PLAZA

Locality:

SECTOR-5, RAJENDER NAGAR

City/Town/Village:

SAHIBABAD

District:

GHAZIABAD

State:

UTTAR PRADESH

Pin Code:

201005

Email Address:

ABHISHEK.AKS97@GMAIL.COM

Mobile Number:

9560843622

Land Line Number:

01125119452

Guardian Details
Qualification

Occupation

Annual Income

Father's/Guardian's:

POST GRADUATE

PRIVATE SERVICE

RS. 400001 -500000

Mother's:

GRADUATE

OTHERS (INCLUDING HOUSE WIFE)

--

Payment Mode:

Credit / Debit Card

Transaction ID:

ASMP3557441738

Exam Fee:

1000 /-

Date of Transaction:

16-11-2014 13:26:26

Card Type:

VISA/Master Card

--

--

Payment Details

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) - 2015. I shall abide by the terms and conditions thereon.

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