JANUARY JEE(MAIN) 2020

Confirmation Page

Application No. 2003 1082 0472 -

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 MAMTA Date of Birth 05-07-2000
Mother's Name LATA PATEL Category OBC- NCL (Central List)
Father's Name ANAND RAM Gender Female
In case of Girl candidate, Are you only girl NO If you are a PwD Candidate, No
child of your parents? do you have benchmark
disability (40% or more /
“Severe” where percentage is
not defined) ?
Nationality Indian Place of Residence Rural
State Code of Eligibility CHHATTISGARH Are You Diabetic? NO
Mode of Preparation Self Study

Apply For
Apply For B.E./B.Tech., B. Arch and B.Planning All Question Paper Medium Hindi
Exam City 1st CHHATTISGARH - BHILAI NAGAR/DURG Exam City 2nd CHHATTISGARH - RAIPUR
Exam City 3rd CHHATTISGARH - BILASPUR Exam City 4th ODISHA - ROURKELA
(CHHATTISGARH)

Additional Details
Are you a Twin No

Contact Details
Address D/O ANAND RAM WARD 7 NAYA PARA MASULGONDI Locality XYZ
MASULGONDI BORTARA BEMETARA SAJA
CHATTISGARH 491993
City/Town/Village MASULGONDI District BEMETARA
State/UT CHHATTISGARH Pin Code 491993
Email Address mah*********@gmail.com Mobile Number (+91) 706****192
Land Line No. with 7067012192
STD code or any
other Contact No.

Fee Payment Details

Payment Mode: Pay through PAYTM Transaction ID: 20190928111212800110168935890091
463
Exam Fee: 650 /- Date of Transaction: 28/09/2019 12:00:00
Fee Submitted On: 28/09/2019
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.

Images Uploaded by Candidate

Photograph Signature

List of Document Uploaded

Photograph,Signature

IP Address : 157.34.109.98 Date of Downloading : 28/09/2019 02:31:16 PM