JANUARY JEE(MAIN) 2020

Confirmation Page

Application No. 2003 1000 0618 -

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

Personal Details
Candidate's Name DEVRAJ SINGH RATHORE Date of Birth 20-10-2002
Mother's Name UMA RATHORE Category General
Father's Name DHARMENDRA SINGH RATHORE Gender Male
If you are a PwD Candidate, do you have No Nationality Indian
benchmark disability (40% or more /
“Severe” where percentage is not defined)
?
Place of Residence Urban State Code of Eligibility MADHYA PRADESH
Are You Diabetic? NO Mode of Preparation Tutorial Classes

Apply For
Apply For B.E./B.Tech. Only Question Paper Medium English
Exam City 1st MADHYA PRADESH - GWALIOR Exam City 2nd MADHYA PRADESH - BHOPAL
Exam City 3rd MADHYA PRADESH - INDORE Exam City 4th MADHYA PRADESH - UJJAIN

Additional Details
Are you a Twin No

Contact Details
Address 22/3, JAYAROGYA HOSPITAL CAMPUS Locality LASHKAR
City/Town/Village GWALIOR District GWALIOR
State/UT MADHYA PRADESH Pin Code 474009
Email Address rde********@gmail.com Mobile Number (+91) 626****592
Land Line No. with --
STD code or any
other Contact No.

Fee Payment Details

Payment Mode: Pay through SBI(MOPS) Transaction ID: CPU5723100
Exam Fee: 650 /- Date of Transaction: 10/09/2019 21:52:14
Fee Submitted On: 10/09/2019
DECLARATION
I hereby declare that all the particulars given by me in this form are true to the best of my knowledge and belief and any mistake / misinformation, detected at the time
of admission or at any stage in future, will result in the cancellation of admission/candidature. I have read the information bulletin and understood all the procedures. In
case I furnish any false information, my result will not be declared/ my candidature will automatically stand cancelled. I shall abide by terms and conditions therein.

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Photograph Signature

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Photograph,Signature

IP Address : 47.247.177.239 Date of Downloading : 10/09/2019 10:02:12 PM