JEE(Main) 2021

Confirmation Page

Application No. 210310100528 210310100528 C

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 PARTHIB PRITOM BORAH Candidate Date of Birth 05-01-2003
Mother's Name SORUMAI BORAH Category General
Father's Name BASANTA BORAH 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, March, April, May Exam State/ City-1st choice ASSAM - DIBRUGARH
Exam State/ City-2nd choice ASSAM - JORHAT Exam State/ City-3rd choice ASSAM - TEZPUR
Exam State/ City-4th choice ASSAM - GUWAHATI

Additional Details
Are you a Twin No

Present Address
Address CHETIA GAON , WARD NO - 5 , NORTH LAKHIMPUR , Locality
ASSAM , PIN - 787001
City/Town/Village LAKHIMPUR TOWN Country India
State ASSAM District LAKHIMPUR
Pin Code 787001 Email Address par***************@gmail.com
Mobile Number 700****112 Alternate Contact No. 7638812722

Fee Payment Details

Payment Mode: Pay through SBI Transaction ID: CPAAMQZGB4
Exam Fee: 2600 /- Date of Transaction: 21/12/2020 22:03:59
Fee Submitted On: 21/12/2020
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

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