JEE(Main) 2021

Confirmation Page

Application No. 210310228171 -

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 MD FAHAD Candidate Date of Birth 10-01-2003
Mother's Name RUKHSANA KHATUN Category Gen-EWS
Father's Name MD AZAM 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/ UT from where 12th/ BIHAR
Equivalent Passed/ Appearing
Are You Diabetic? NO Mode of Preparation Self Study
Medium of Schooling in Qualifying Hindi
Examination

Applied For
Apply For B.E./B.Tech. Only Question Paper Medium Hindi
Session(s) of Exam Apply For February Exam State/ City-1st choice BIHAR - BEGUSARAI
Exam State/ City-2nd choice BIHAR - PATNA Exam State/ City-3rd choice BIHAR - MUZAFFARPUR
Exam State/ City-4th choice BIHAR - SAMASTIPUR

Additional Details
Are you a Twin No

Present Address
Address WARD NO 04 Locality BALUARA MASJID
City/Town/Village BALUARA NINGA Country India
State BIHAR District BEGUSARAI
Pin Code 851112 Email Address MDF*****@GMAIL.COM
Mobile Number 720****700 Alternate Contact No. 9709815909

Fee Payment Details

Payment Mode: Pay through HDFC Bank Transaction ID: 11925906303
Exam Fee: 650 /- Date of Transaction: 27/12/2020 12:41:01
Fee Submitted On: 27/12/2020
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 (with 80% face without mask),Signature,Category Certificate

IP Address : 106.207.22.179 Date of Downloading : 05/03/2021 08:47:35 AM