Joint Entrance Examination (Main) - 2017

CENTRAL BOARD OF SECONDARY EDUCATION

ACKNOWLEDGEMENT PAGE

Application No.

70243844
DO NOT SEND THIS PAGE TO CBSE.

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

Personal Details
Name:

LAMAN ANSARI

Date of Birth:

02/02/1999

Mother's Name:

FARHA ANSARI

Category

GENERAL

Father's Name:

LAIQ AHMAD ANSARI

Person with Disability(PwD):

NO

State of Eligibility:

RAJASTHAN

Percentage of Disability:

--

Gender:

MALE

Are you the only child?:

NO

Nationality:

INDIAN

Place of Residence:

URBAN

Aadhaar Number

563606220828

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:

JAIPUR

2nd Choice of Exam Centre:

AJMER

3rd Choice of Exam Centre:

DELHI/NEW DELHI

4th Choice of Exam Centre:

KOTA

Academic Details
Year of passing class 10th:

2015

Year of Passing or Appearing class 12th/Qualifying Exam: 2017

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:

Jayshree Periwal high school Chitrakoot, Jaipur, Rajasthan, 302021

Candidate's Mailing Address

Country:

India

State:

RAJASTHAN

District:

JAIPUR

Address:

560, udai Path, Vivek Vihar

Locality:

Shyam Nagar

City/Town/Village:

Jaipur

Pin Code:

302019

Email Address:

ansarilaman@gmail.com

Mobile Number:

9460336555

Land Line Number:

1412290930

Guardian Details
Qualification

Occupation

Annual Income

Father's/Guardian's:

GRADUATE

BUSINESS

RS. 800001 AND ABOVE

Mother's:

GRADUATE

OTHERS (INCLUDING HOUSE WIFE)

UPTO 100000

Provider Name:

Syndicate Bank Payment Gateway

Payment Mode:

Electronic Payment Gateway

Fee Type:

Examination Fee

Transaction Amount:

1000 /-

Transaction ID:

HAXG4964619897

Date of Transaction:

12-12-2016 14:16:31

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) - 2017. I shall abide by the terms and conditions thereon.

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