Joint Entrance Examination (Main) - 2016CENTRAL BOARD OF SECONDARY EDUCATION

ACKNOWLEDGEMENT PAGE

Application No. 60441924DO NOT SEND THIS PAGE TO CBSE.

CANDIDATES ARE REQUESTED TO RETAIN THE PRINTOUT OF ACKNOWLEDGEMENT PAGE FOR FUTURE REFERENCE.

Personal DetailsName: EVEN TARASH TUDU Date of Birth: 28/09/1997

Mother's Name: BIJAMANI TUDU Category ST

Father's Name: DEEPAK KUMAR TUDU Person with Disability(PwD): NO

State of Eligibility: ODISHA Percentage of Disability: --

Gender: MALE Are you the only child?: NO

Nationality: INDIAN Place of Residence: URBAN

Aadhaar Number (UIDAI): -- You need scribe/reader ?: NO

Examination DetailsApplying 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: BHUBANESWAR 2nd Choice of Exam Centre: CUTTACK

3rd Choice of Exam Centre: BALASORE 4th Choice of Exam Centre: BERHAMPUR

Academic DetailsYear 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: ODISHA COUNCIL OF HIGHER SECONDARY EDUCATION

Name of the Qualifying Examination passed / appearing: Intermediate or two-year Pre-University examination conducted by a recognized Board/ University.

Percentage of Marks in Class 12th/Qualifying Exam: 61.66 Roll No. of Class 12th/Qualifying Exam: 303MA356

Appeared/Appearing for Improvement of Class12th/Qualifying Exam:

NO Mode of preperation: SELF STUDY

Name and Address of the School/College from wherepassed/appearing:

BJB JUNIOR COLLEGE, BHUBANESWAR Kalpana Road, Infront Of Court, Bhubaneswar, Odisha 751014

Candidate's Mailing AddressAddress: QRT NO. 346, IMMT COLONY Locality: Acharya Vihar

City/Town/Village: Bhubaneswar District: Khurda

State: ODISHA Pin Code: 751013

Email Address: event2do@gmail.com Mobile Number: 9776973476

Land Line Number: 06742379274

Guardian DetailsQualification Occupation Annual Income

Father's/Guardian's: GRADUATE GOVERNMENT SERVICE RS. 500001-600000

Mother's: GRADUATE OTHERS (INCLUDING HOUSE WIFE) UPTO 100000

Payment DetailsPayment Mode: HDFC Bank e-Challan Transaction ID: 60441924

Exam Fee: 500 /- Branch Name/Code: 1252

Deposit Date: 22/12/2015 -- --

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 bothJEE(Main) and JEE(Advanced) - 2016. I shall abide by the terms and conditions thereon.

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