Joint Entrance Examination (Main) - 2017

CENTRAL BOARD OF SECONDARY EDUCATION

ACKNOWLEDGEMENT PAGE

Application No. 71099091

DO NOT SEND THIS PAGE TO CBSE.
CANDIDATES ARE REQUESTED TO RETAIN THE PRINTOUT OF ACKNOWLEDGEMENT PAGE FOR FUTURE REFERENCE.

Personal Details
Name: REVANTH JAI SARAN SELVAM Date of Birth: 05/12/1999
Mother's Name: NAGAJOTHI Category OBC- NCL (CENTRAL LIST)
Father's Name: SELVAM Person with Disability(PwD): NO
State of Eligibility: TAMIL NADU Percentage of Disability: --
Gender: MALE In case of girl candidate, Are NO
you the only child of your
parents?:
Nationality: INDIAN Place of Residence: RURAL
Aadhaar Number 480890124419 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: MADURAI 2nd Choice of Exam Centre: COIMBATORE
3rd Choice of Exam Centre: CHENNAI 4th Choice of Exam Centre: BENGALURU

Academic Details
Year of passing class 10th: 2015 Place of 12th class schooling: VILLAGE
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: TAMIL NADU BOARD OF HIGHER SECONDARY EDUCATION
Name of the Qualifying Examination passed / appearing: Any Public School/ Board/ University examination in India or in any foreign country recognized as equivalent to
the 10+2 system by the Association of Indian Universities (AIU).
Percentage of Marks in Class 12th/Qualifying Exam: -- Roll No. of Class 12th/Qualifying Exam: --
Appeared/Appearing for Improvement of Class NO 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 SAMABHARATHAM MATRIC HR.SEC.SCHOOL KILANGULAM PERAIYUR TALUKA MADURAI DIST-625703
passed/appearing:

Candidate's Mailing Address

Country: India State: TAMIL NADU
District: MADURAI Address: 45C/1D ARUMUGAM NORTH SECOND STREET
KAMARAJAPURAM
Locality: THIRUMANGALAM City/Town/Village: MADURAI
Pin Code: 625706 Email Address: alagarraja83@gmail.com
Mobile Number: 9003390710 Land Line Number: --

Guardian Details
Qualification Occupation Annual Income
Father's/Guardian's: GRADUATE PRIVATE SERVICE RS. 200001 - 300000
Mother's: GRADUATE GOVERNMENT SERVICE RS. 300001 -400000

Payment Details
Provider Name: HDFC Bank Payment Gateway Payment Mode: Electronic Payment Gateway
Fee Type: Examination Fee Transaction Amount: 1000 /-
Transaction ID: HHMP5023653322 Date of Transaction: 04-01-2017 19:26:52
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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