JANUARY JEE(MAIN) 2020

Confirmation Page

Application No. 2003 1013 9027 -

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 VAIBHAV AGRAWAL Date of Birth 23-05-2002
Mother's Name SANGITA AGRAWAL Category General
Father's Name SAMIR AGRAWAL 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 Rural 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 - ROURKELA Exam City 2nd ODISHA - SAMBALPUR
Exam City 3rd JHARKHAND - RANCHI Exam City 4th ODISHA - BHUBANESWAR

Additional Details
Are you a Twin No

Contact Details
Address KALINGA TOWER,504 Locality DCBL WEST COLONY
City/Town/Village RAJGANGPUR District SUNDARGARH
State/UT ODISHA Pin Code 770017
Email Address agr*********@yahoo.co.in Mobile Number (+91) 876****785
Land Line No. with 7008405019
STD code or any
other Contact No.

Fee Payment Details

Payment Mode: Pay through SBI(MOPS) Transaction ID: IGAGYNSHN4
Exam Fee: 650 /- Date of Transaction: 08/09/2019 21:26:52
Fee Submitted On: 08/09/2019
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

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