JANUARY JEE(MAIN) 2020

Confirmation Page

Application No. 200310006019 -

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 KRUNAL VASAVA Date of Birth 23-02-2002
Mother's Name NIRUBEN Category ST
Father's Name MANOJKUMAR 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 Code of Eligibility GUJARAT
Are You Diabetic? NO Mode of Preparation Self Study

Apply For
Apply For B.E./B.Tech. Only Question Paper Medium English
Exam City 1st GUJARAT - VADODARA Exam City 2nd GUJARAT - ANAND
Exam City 3rd GUJARAT - AHMEDABAD/GANDHINAGAR Exam City 4th GUJARAT - SURAT

Additional Details
Are you a Twin No

Contact Details
Address E-69 SHREE RAJJI PARK SOCIETY Locality NEAR VALLABH VIDHYA MANDIR SCHOOL
City/Town/Village WAGHODIA DABHOI RING ROAD VADODARA District VADODARA
State/UT GUJARAT Pin Code 390025
Email Address kru************@gmail.com Mobile Number (+91) 972****437
Land Line No. with --
STD code or any
other Contact No.

Fee Payment Details

Payment Mode: Pay through PAYTM Transaction ID: 20190908111212800110168654187079
374
Exam Fee: 325 /- Date of Transaction: 08/09/2019 12:00:00
Fee Submitted On: 08/09/2019
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,Signature

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