Joint Entrance Examination (Main) - 2015

CENTRAL BOARD OF SECONDARY EDUCATION

ACKNOWLEDGEMENT PAGE

Application No.

50448792
DO NOT SEND THIS PAGE TO CBSE.

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

Personal Details
Name:

VENKATESH BHARADWAJ.S

Date of Birth:

07/10/1997

Mother's Name:

G.MAHALAKSHMI

Category

GENERAL

Father's Name:

N.SRINIVASAN

Person with Disability(PwD):

NO

State of Eligibility:

TAMIL NADU

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:

PUDUCHERRY

2nd Choice of Exam Centre:

COIMBATORE

3rd Choice of Exam Centre:

MADURAI

4th Choice of Exam Centre:

TIRUPATI

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:

COACHING

Roll Number of Class 12th/Qualifying Examination of

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

MAHARISHI VIDYA MANDIR SENIOR SECONDARY SCHOOL 28,DR.GURUSWAMY

ROAD,CHETPET,CHENNAI-31

Candidate's Mailing Address

Address:

3/51,ANTONA FLATS,AYYAVOO STREET

Locality:

SHENOY NAGAR

City/Town/Village:

CHENNAI

District:

CHENNAI

State:

TAMIL NADU

Pin Code:

600030

Email Address:

seeni1967@gmail.com

Mobile Number:

9442978229

Land Line Number:

04426640509

Guardian Details
Qualification

Occupation

Annual Income

Father's/Guardian's:

GRADUATE

GOVERNMENT SERVICE

RS. 700001-800000

Mother's:

POST GRADUATE

TEACHING / RESEARCH

RS. 200001 - 300000

Payment Mode:

Credit / Debit Card

Transaction ID:

AIOD3565407356

Exam Fee:

1000 /-

Date of Transaction:

22-11-2014 20:35:11

Card Type:

VISA/Master Card

--

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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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