CENTRAL BOARD OF SECONDARY EDUCATION

CONFIRMATION PAGE - NEET(UG)-2018

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Application / Registration No. : 41358386

Candidate's Name SOUMYA SHRIVAS Date of Birth 02/09/2000

Mother's Name MONGRA BAI Gender Female
SHRIVAS
Father's Name JAGANNATH PRASAD Category OBC
SHRIVAS
Year of Passing/Appearing Class 2018 Person with Disability: No
XII
State/Country to which Applicant Chhatisgarh Nationality Indian
belongs
Question Paper Medium Hindi Class XII Marks(%) -
Mobile No. 91xxxxxx3223 Email Id soxxxxxxxxxxxx@gmail
.com
Choice of Exam Centres BILASPUR ( 5019) RAIPUR ( 5020) NAGPUR ( 5085)

DECLARATION :- I hereby solemnly and sincerely affirm that all the particulars stated by me in the Application Form are
true and correct. Even the spelling of names and category are also correct. I have not concealed any information
including information about previous attempts in AIPMT/NEET. However, if any information furnished herein is found
fraudulent, incorrect or untrue, I understand that I will be liable for criminal prosecution which will result incancellation of
my candidature. Further that the selection and admission to the course is liable to be cancelled. I agree to abide by the
Rules and Regulations governing the Examination as contained in the Information Bulletin for NEET, 2018 which I have
gone through carefully. I further declare that I have not submitted any other application for NEET, 2018 and mobile no
and email address given in the form are correct and my own or of my parents.

Photo Signature
Complete Mailing Address
Address VILL -BUNDELA, BUNDELA, SANTOSHI CHOWK
City VIA -KHAROD ,JANJGIR - CHAMPA
State/Country Chhatisgarh Pin Code 495556
Details of Transaction(SBI Bank)
Transaction ID.: CH77381417 Total Amount: 1400 Date of Transaction: 3/8/2018 8:17:01 PM
Card Type: VISA/Master Card
Registration No: 41358386 Printed On : 08/03/2018