Conrmation Page

Application from Private Candidate for Main Examination

2017
The Regional Ocer
Central Board of Secondary Education
Behind State Bank Colony, Near Brahmsthan,
Sheikhpura, Bailey Road
Patna-800 014.

Application Details
Class:

12

Application Failure
Category:

Application No.:

PF203952

Roll No.:

Candidate's Name and Address

9771690171
singhsuresh784@gmail.com

SURAJ KUMAR
P-1/6,VIDYAPURI,KANKARBAGH
PATNA

7639509 - 2016

800020
PATNA
BR
Mother's Name:RATNA DEVI
Father's Name:VIJAY KUMAR
Gender: Male
Csste: OBC
Dierently Abled(If Applicable):
Subject(s)

041 - MATHEMATICS
042 - PHYSICS
043 - CHEMISTRY
048 - PHYSICAL EDUCATION
301 - ENGLISH CORE

Fee Details (INR):

1140(Latefee : 0)

Paymode: EC Payment 04/11/2016

HDF :
Date:
112159

Note:
Please send this page along with proof of fee to Regional Oce concerned on the
address mentioned above. In case of fee paid thourgh Demand Draft, please
write your roll no. and application no. on backside of demand draft. Application
will be successful subject to realisation of demand draft (in case payment made
through demand draft).
Submission of form and fee does not make the candidate eligible for appearing
for the examination. His/her eligibility will depend upon the fullment of the
eligibility conditions prescribed by the Board and their verication at Board's
end.
Candidate will have to send Photostat copy of the Marksheet/Grade sheet cum
Certicate of Performance of the Roll No. lled in the application form and copy
of e-challan/DD alongwith the conrmation page to the concerned Regional
Oce. Fresh female candidate appearing under Delhi Scheme will also have to
send the Adavit.
Signature of Candidate
Date: 04/11/2016