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CONFIRMATION PAGE - AIPMT- 2015

Application / Registration No.

6246338

You have successfully submitted Application On-line. Kindly take the printout of this page. Please preserve this form along with original E-C hallan (if fee
paid by E-C hallan) for future reference.
C andidate's Name

SA NTHOSH S C

Date of Birth

15/07/1997

Mother's Name

A NUSUYA M

Gender

Male

Father's Name

CHA NDRA PPA S K

C ategory

OBC

Year of Passing/Appearing C lass

XII

2015

Person with Disability

No

State/C ountry to which Applicant

belongs

Karnataka

Nationality

Indian

Question Paper Medium

English

C lass XII Marks(%)

Mobile No.

91-9900330114

Email Id

skchandrappasnc65@gmail.com

C hoice of Exam C entres

(1) BA NGA LORE ( 518)

(2) MUMBA I ( 527)

(3) DELHI ( 508)

(1) 1st State : NA

(2) 2nd State : NA

(3) 3rd State : NA

(4) A LL India: Yes /( OBC )

(5) Participating UNIV./INST. : Yes

Option For Seats/Eligible C ategory

DECLARATION: - I hereby solemnly and sincerely affirm that all the particulars stated by me in this Application Form are true and correct. I have not
concealed any information. However, if any information furnished herein is found fraudulent , incorrect or untrue, I understand that I will be liable to
criminal prosecution and I also agree to forego my seat. 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 AIPMT - 2015 Information Bulletin available on website, which I have duly
gone through. I further declare that I have not submitted any other application for AIPMT-2015 and mobile no and email address are correct and are
given in the form of my own or of my parents.

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Signature

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Complete mailing address:
Address

61, 3RD C ROSS, NEAR VIDYANIKETHAN SC HOOL, MADDURAMMA

LAYOUT

C ity

SUNKADAKATTE

State /C ountry

Karnataka

Pin C ode

560091

Details of Transaction.
Transaction ID:6246338

Amount:1200

Date of Deposit :20141223

Bank Name :HDFC Bank

Bank Office Name & Address:Malleshwaram 18th Cross( micr code : MC0001), ,

Registration No:

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6246338

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Printed On : 09/03/2015

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