Joint Entrance Examination (Main) - 2018

CENTRAL BOARD OF SECONDARY EDUCATION

ACKNOWLEDGEMENT PAGE

Application No. 80109443

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

Personal Details
Name: RISHABH MISHRA Date of Birth: 22/12/1999
Mother's Name: SHOBHA MISHRA Category GENERAL
Caste Name NA Father's Name: ABHIMANYU MISHRA
Person with Disability(PwD): NO State of Eligibility: UTTAR PRADESH
Percentage of Disability: -- Gender: MALE
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: COMPUTER BASED EXAMINATION Question Paper Medium: ENGLISH
Choice of Online Exam Centre: DELHI

Academic Details
Year of passing class 10th: 2016 Place of 12th class schooling: CITY
Year of Passing or Appearing class 12th/Qualifying Exam: 2018 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 NO Mode of preperation: COACHING
12th/Qualifying Exam:
Roll Number of Class 12th/Qualifying Examination of
Improvement Examination:
Name and Address of the School/College from where SETH ANANDRAM JAIPURIA SCHOOL SEC 14 VASUNDHARA GHAZIABAD
passed/appearing:

Candidate's Mailing Address

Country: India State: UTTAR PRADESH
District: GHAZIABAD Address: HOUSE NO. 71 NEAR SHIV MANDIR
Locality: PRAHALADGHARI City/Town/Village: VASUNDHARA
Pin Code: 201012 Email Address: ris****com
Mobile Number: 995****357

Guardian Details
Qualification Occupation Annual Income
Father's/Guardian's: MATRICULATE PRIVATE SERVICE RS. 100001 -200000
Mother's: MATRICULATE PRIVATE SERVICE UPTO 100000

Payment Details
Provider Name: Syndicate Bank Payment Gateway Payment Mode: Electronic Payment Gateway
Fee Type: Examination Fee Transaction Amount: 500 /-
Transaction ID: LSM35883643580 Date of Transaction: 13-12-2017 19:46:48

Selected Date for Computer Based Examination of Paper-1

Your selected date for Computer Based Examination: 15/04/2018
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