Combined Entrance Examination, 2022 (CEE-2022) for admission to B.

Tech Programme in the

State of Assam
Application no: 22004079

Programme : BTECH

Name as Per Certificate or Marksheet * : IMAN SHIVAM

Father Name : RAMESH NATH

Mother Name : JONALI DAS

Date of Birth : 16/02/2004

Exam Center : 2 - Bongaigaon

Gender : Male
Are You a Permanent Resident of Assam ? : Yes
Address : ABHAYAPURI WARD NO 5
NEAR CINEMA HALL
PO ABHAYAPURI
Pin Code : 783384
City : ABHAYAPURI
Dist : BONGAIGAON
State : ASSAM
Nationality : Indian
Phone No. : -0
Mobile No. : 9854290320
E-Mail. : imansshivam@gmail.com
Category : 5 - OBC/MOBC -OTHER (NONE,)
EWS : NO
Have You Passed Your Qualification Examination Without
RESULT AWAITED
Grace and Single Sitting* :
Are You B.Sc Passed ? : NO
Candidate's Declaration:

I declare that the entries in the Online Application Form have been filled up and the entries made are correct as per my documents
and to the best of my knowledge and belief.I have verified my eligibility criteria from information broucher CEE-2022,I fulfilled the
conditions with the same.
I agree that if any statement is proved to be false then the Authority shall have the right to take legal action against me for
submitting false information or statement.
I further declare that there is no allegation of misconduct against me and I have never been convicted for any offence involving
moral turpitude.

Date : ______________

Place : _____________