JANUARY JEE(MAIN) 2020

Confirmation Page

Application No. 2003 1025 2427 -

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 HIMANSHU SURYAWANSHI Date of Birth 17-05-2002
Mother's Name SARLA SURYAWANSHI Category OBC- NCL (Central List)
Father's Name GAJANAN SURYAWANSHI 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 CHHATTISGARH
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 CHHATTISGARH - BHILAI NAGAR/DURG Exam City 2nd CHHATTISGARH - RAIPUR
Exam City 3rd MAHARASHTRA - NAGPUR Exam City 4th MAHARASHTRA - AMRAVATI

Additional Details
Are you a Twin No

Contact Details
Address NEAR SARASWATI GYAN MANDIR ,BESIDE TANU Locality
PALACE,KADAMBARI NAGAR ,DURG
City/Town/Village DURG District DURG
State/UT CHHATTISGARH Pin Code 491001
Email Address gaj****************@gmail.com Mobile Number (+91) 932****486
Land Line No. with --
STD code or any
other Contact No.

Fee Payment Details

Payment Mode: Pay through SBI(MOPS) Transaction ID: IGAHCSSCA8
Exam Fee: 650 /- Date of Transaction: 30/09/2019 10:51:15
Fee Submitted On: 30/09/2019
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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