Joint Entrance Examination (Main) - 2018

CENTRAL BOARD OF SECONDARY EDUCATION

ACKNOWLEDGEMENT PAGE

Application No. 80982660

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

Personal Details
Name: SAHAJ SHUKLA Date of Birth: 02/07/1999
Mother's Name: AYOGIKA SHUKLA Category GENERAL
Caste Name NA Father's Name: RAJESH KUMAR SHUKLA
Person with Disability(PwD): NO State of Eligibility: UTTAR PRADESH
Percentage of Disability: -- Gender: FEMALE
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: ROORKEE 2nd Choice of Exam Centre: DELHI
3rd Choice of Exam Centre: KANPUR 4th Choice of Exam Centre: LUCKNOW

Academic Details
Year of passing class 10th: 2015 Place of 12th class schooling: CITY
Year of Passing or Appearing class 12th/Qualifying Exam: 2017 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: 71.60 Roll No. of Class 12th/Qualifying Exam: 5888847
Appeared/Appearing for Improvement of Class YES 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 GODWIN PUBLIC SCHOOL FAZALPUR MEERUT UP
passed/appearing:

Candidate's Mailing Address

Country: India State: UTTAR PRADESH
District: MEERUT Address: B-16/1 NAND VIHAR
Locality: ROHTA ROAD City/Town/Village: MEERUT
Pin Code: 250002 Email Address: sah*******@rediffmail.com
Mobile Number: 902****530

Guardian Details
Qualification Occupation Annual Income
Father's/Guardian's: GRADUATE SELF EMPLOYMENT RS. 200001 - 300000
Mother's: POST GRADUATE TEACHING / RESEARCH RS. 100001 -200000

Payment Details
Provider Name: HDFC Bank Payment Gateway Payment Mode: Electronic Payment Gateway
Fee Type: Examination Fee Transaction Amount: 500 /-
Transaction ID: LHMP5921133538 Date of Transaction: 28-12-2017 21:23:58
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