jee(main) acknowledgementpage(1)

Joint Entrance Examination (Main) - 2015 CENTRAL BOARD OF SECONDARY EDUCATION ACKNOWLEDGEMENT PAGE Application No. 50448792 DO NOT SEND THIS PAGE TO CBSE. CANDIDATES ARE REQUESTED TO RETAIN THE PRINTOUT OF ACKNOWLEDGEMENT PAGE FOR FUTURE REFERENCE. Personal Details Name: VENKATESH BHARADWAJ.S Date of Birth: 07/10/1997 Mother's Name: G.MAHALAKSHMI Category GENERAL Father's Name: N.SRINIVASAN Person with Disability(PwD): NO State of Eligibility: TAMIL NADU 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 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: PUDUCHERRY 2nd Choice of Exam Centre: COIMBATORE 3rd Choice of Exam Centre: MADURAI 4th Choice of Exam Centre: TIRUPATI 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: 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 12th/Qualifying Exam: NO Mode of preperation: COACHING Roll Number of Class 12th/Qualifying Examination of Improvement Examination: Name and Address of the School/College from where passed/appearing: MAHARISHI VIDYA MANDIR SENIOR SECONDARY SCHOOL 28,DR.GURUSWAMY ROAD,CHETPET,CHENNAI-31 Candidate's Mailing Address Address: 3/51,ANTONA FLATS,AYYAVOO STREET Locality: SHENOY NAGAR City/Town/Village: CHENNAI District: CHENNAI State: TAMIL NADU Pin Code: 600030 Email Address: [email protected] Mobile Number: 9442978229 Land Line Number: 04426640509 Guardian Details Qualification Occupation Annual Income Father's/Guardian's: GRADUATE GOVERNMENT SERVICE RS. 700001-800000 Mother's: POST GRADUATE TEACHING / RESEARCH RS. 200001 - 300000 Payment Details Payment Mode: Credit / Debit Card Transaction ID: AIOD3565407356 Exam Fee: 1000 /- Date of Transaction: 22-11-2014 20:35:11 Card Type: VISA/Master Card -- -- 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) - 2015. I shall abide by the terms and conditions thereon. Images Uploaded by Candidate Photograph Signature Thumb Impression

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Joint Entrance Examination (Main) - 2015CENTRAL BOARD OF SECONDARY EDUCATION

ACKNOWLEDGEMENT PAGE

Application No. 50448792DO NOT SEND THIS PAGE TO CBSE.

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

Personal DetailsName: VENKATESH BHARADWAJ.S Date of Birth: 07/10/1997Mother's Name: G.MAHALAKSHMI Category GENERALFather's Name: N.SRINIVASAN Person with Disability(PwD): NOState of Eligibility: TAMIL NADU Percentage of Disability: --Gender: MALE Are you the only child?: NONationality: INDIAN Place of Residence: URBANAadhaar Number (UIDAI): -- You need scribe/reader ?: NOExamination DetailsApplying For: JEE(Main) Paper - 1 (B.E./B.Tech.) OnlyMode of Examination: PEN AND PAPER BASED EXAMINATION Question Paper Medium: ENGLISH1st Choice of Exam Centre: PUDUCHERRY 2nd Choice of Exam Centre: COIMBATORE3rd Choice of Exam Centre: MADURAI 4th Choice of Exam Centre: TIRUPATI

Academic DetailsYear of passing class 10th: 2013 Place of 12th class schooling: CITYYear of Passing or Appearing class 12th/Qualifying Exam: 2015 Type of Institution of Class 12th/Qualifying Exam: PRIVATESchool Board of class 12th/Qualifying Exam: CENTRAL BOARD OF SECONDARY EDUCATIONName 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 Class12th/Qualifying Exam:

NO Mode of preperation: COACHING

Roll Number of Class 12th/Qualifying Examination ofImprovement Examination:Name and Address of the School/College from wherepassed/appearing:

MAHARISHI VIDYA MANDIR SENIOR SECONDARY SCHOOL 28,DR.GURUSWAMYROAD,CHETPET,CHENNAI-31

Candidate's Mailing AddressAddress: 3/51,ANTONA FLATS,AYYAVOO STREET Locality: SHENOY NAGARCity/Town/Village: CHENNAI District: CHENNAIState: TAMIL NADU Pin Code: 600030Email Address: [email protected] Mobile Number: 9442978229Land Line Number: 04426640509

Guardian DetailsQualification Occupation Annual Income

Father's/Guardian's: GRADUATE GOVERNMENT SERVICE RS. 700001-800000Mother's: POST GRADUATE TEACHING / RESEARCH RS. 200001 - 300000

Payment DetailsPayment Mode: Credit / Debit Card Transaction ID: AIOD3565407356Exam Fee: 1000 /- Date of Transaction: 22-11-2014 20:35:11Card Type: VISA/Master Card -- --

DECLARATIONI 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) - 2015. I shall abide by the terms and conditions thereon.Images Uploaded by Candidate

Photograph Signature Thumb Impression