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Joint Entrance Examination (Main) 2019

NATIONAL TESTING AGENCY


CONFIRMATION PAGE

Application No. 190310757741


DO NOT SEND THIS PAGE TO NATIONAL TESTING AGENCY(NTA).
CANDIDATES ARE REQUESTED TO RETAIN THE PRINTOUT OF CONFIRMATION PAGE FOR FUTURE REFERENCE.

Personal Details
Name: KHAMMA LOTZEM Date of Birth: 15/10/1998
Mother's Name: HOICHONG LOTZEM Category: ST
Caste Name: THADOU KUKI Father's Name: SONGLAL LOTZEM
Person with Disability(PwD): NO State of Eligibility: MANIPUR
Percentage of Disability: -- Gender: MALE
Are you Diabetic: NO Nationality: INDIAN
Place of Residence: URBAN Do you need scribe: NO

Examination Details
Applying For: JEE(Main) Paper - 1 (B.E./B.Tech.) Only
Mode of Examination: COMPUTER BASED EXAMINATION Question Paper Medium: ENGLISH
1st Choice of Exam City: IMPHAL 2nd Choice of Exam City: DIMAPUR
3rd Choice of Exam City: GUWAHATI 4th Choice of Exam City: SHILLONG

Academic Details
Year of passing class 10th: 2013 Place of 12th class schooling: VILLAGE
Year of Passing or Appearing class 12th/Qualifying Exam: 2017 Type of Institution of Class 12th/Qualifying Exam: GOVERNMENT
School Board of class 12th/Qualifying Exam: CENTRAL BOARD OF SECONDARY EDUCATION
Name of the Qualifying Exam 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: 70 Roll No. of Class 12th/Qualifying Exam: 3636942
Appeared/Appearing for Improvement of Class NO Mode of preperation: SELF STUDY
12th/Qualifying Exam:
Roll Number of Class 12th/Qualifying Exam of --
Improvement Exam:
Name and Address of the School/College from where JAWAHAR NAVODAYA VIDYALAYA LIWA KHULLEN, SAREI, CHANDEL
passed/appearing:

Candidate's Mailing Address


Country: India State: MANIPUR
District: CHANDEL Address: PHAICHAM VENG MOREH, WARD NO.3
Locality: MOREH City/Town/Village: TOWN
Pin Code: 795131 Email Address: KHA*******@GMAIL.COM
Mobile Number: 762****804

Guardian Details
Qualification Occupation Annual Income
Father's/Guardian's: GRADUATE AGRICULTURE UPTO 100000
Mother's: MATRICULATE OTHERS UPTO 100000

Payment Details
Provider Name: State Bank of India (MOPS) Payment Mode: Electronic Payment Gateway
Fee Type: Examination Fee Transaction Amount: 250 /-
Transaction ID: CPK0963782 Date of Transaction: 26/09/2018 21:36:57
DECLARATION
I hereby declare that all the particulars stated in this application form are true to the best of my knowledge and belief.
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