JANUARY JEE(MAIN) 2020

Confirmation Page

Application No. 2003 1035 6556 -

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 JYOTI RANJAN DASH Date of Birth 06-07-2002
Mother's Name SASMITA DASH Category General
Father's Name JAYA KRUSHNA DASH 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 ODISHA
Are You Diabetic? NO Mode of Preparation Self Study

Apply For
Apply For B.E./B.Tech. Only Question Paper Medium English
Exam City 1st ODISHA - BALASORE Exam City 2nd ODISHA - CUTTACK
Exam City 3rd ODISHA - BHUBANESWAR Exam City 4th ODISHA - ROURKELA

Additional Details
Are you a Twin No

Contact Details
Address SIDHESWAR COLONY , GANESHWARPUR , REMUNA Locality INDIAN
GOLEI
City/Town/Village BALESWAR District BALASORE
State/UT ODISHA Pin Code 756019
Email Address jay*************@gmail.com Mobile Number (+91) 824****960
Land Line No. with 9861275097
STD code or any
other Contact No.

Fee Payment Details

Payment Mode: Pay through PAYTM Transaction ID: 20190917111212800110168837388280
967
Exam Fee: 650 /- Date of Transaction: 17/09/2019 12:00:00
Fee Submitted On: 17/09/2019
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

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