JEE(Main) 2021

Confirmation Page

Application No. 210310461961 -

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 RAJIV KUMAR SAH Candidate Date of Birth 30-09-2001
Mother's Name KALASIA DEVI Category OBC- NCL (Central List)
Father's Name NAND KISHORE SAH 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/ UT from where 12th/ ASSAM
Equivalent Passed/ Appearing
Are You Diabetic? NO Mode of Preparation Self Study
Medium of Schooling in Qualifying English
Examination

Applied For
Apply For B.E./B.Tech. Only Question Paper Medium English
Session(s) of Exam Apply For February Exam State/ City-1st choice ASSAM - DIBRUGARH
Exam State/ City-2nd choice ARUNACHAL PRADESH - Exam State/ City-3rd choice ASSAM - JORHAT
ITANAGAR/NAHARLAGUN
Exam State/ City-4th choice ASSAM - TEZPUR

Additional Details
Are you a Twin No

Present Address
Address ALOKA HOSTEL,PURNIMA NAGAR,BORBIL Locality
NO.1,DIGBOI
City/Town/Village DIGBOI Country India
State ASSAM District TINSUKIA
Pin Code 786171 Email Address raj********@gmail.com
Mobile Number 700****647 Alternate Contact No. 9612598712

Fee Payment Details

Payment Mode: Pay through SBI(MOPS) Transaction ID: CPAANTAWY7
Exam Fee: 650 /- Date of Transaction: 06/01/2021 21:51:50
Fee Submitted On: 06/01/2021
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 : 47.29.191.216 Date of Downloading : 06/01/2021 10:03:22 PM