Joint Entrance Examination (Main) - 2017

CENTRAL BOARD OF SECONDARY EDUCATION

ACKNOWLEDGEMENT PAGE

Application No. 70710095

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

Personal Details
Name: PREETI GAUTAM Date of Birth: 20/09/1999
Mother's Name: USHA RANI Category SC
Father's Name: NARESH KUMAR Person with Disability(PwD): NO
State of Eligibility: DELHI Percentage of Disability: --
Gender: FEMALE Are you the only child?: NO
Nationality: INDIAN Place of Residence: URBAN
Aadhaar Number 613361271053 You need scribe/reader ?: NO

Examination Details
Applying For:
Mode of Examination:
1st Choice of Exam Centre:
3rd Choice of Exam Centre:
JEE(Main) Paper - 1 (B.E./B.Tech.) Only
PEN AND PAPER BASED EXAMINATION Question Paper Medium: ENGLISH
DELHI/NEW DELHI 2nd Choice of Exam Centre: FARIDABAD
GURGAON 4th Choice of Exam Centre: HISAR

Academic Details
Year of passing class 10th: 2013 Place of 12th class schooling: CITY
Year of Passing or Appearing class 12th/Qualifying Exam: 2015 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 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: 50.9 Roll No. of Class 12th/Qualifying Exam: 9194231
Appeared/Appearing for Improvement of Class YES 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 Kendriya Vidyalaya Rajokri Kendriya Vidyalaya A.F.S Rajokri, N.D
passed/appearing:

Candidate's Mailing Address

Country: India State: DELHI
District: SOUTH DELHI Address: I-9 CPWD FLATS,NANAKPURA
Locality: SOUTH MOTIBAGH City/Town/Village: DELHI
Pin Code: 110021 Email Address: preetigautam220@gmail.com
Mobile Number: 9650810827 Land Line Number: --

Guardian Details
Qualification Occupation Annual Income
Father's/Guardian's: GRADUATE PRIVATE SERVICE RS. 300001 -400000
Mother's: GRADUATE GOVERNMENT SERVICE RS. 400001 -500000

Payment Details
Provider Name: HDFC Bank Payment Gateway Payment Mode: Electronic Payment Gateway
Fee Type: Examination Fee Transaction Amount: 500 /-
Transaction ID: HHMP4997726260 Date of Transaction: 24-12-2016 21:29:48
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.

Images Uploaded by Candidate

Photograph Signature