JANUARY JEE(MAIN) 2020

Confirmation Page

Application No. 2003 1071 8182 -

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 CHIRAYU AGRAWAL Date of Birth 27-11-2001
Mother's Name TRAPTI AGRAWAL Category Gen-EWS
Father's Name SHYAM AGRAWAL 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 MADHYA PRADESH
Are You Diabetic? NO Mode of Preparation Tutorial Classes

Apply For
Apply For B.E./B.Tech. Only Question Paper Medium English
Exam City 1st MADHYA PRADESH - BHOPAL Exam City 2nd MADHYA PRADESH - INDORE
Exam City 3rd MADHYA PRADESH - UJJAIN Exam City 4th MADHYA PRADESH - GWALIOR

Additional Details
Are you a Twin No

Contact Details
Address PLOT NO.16 PANCHSHEEL NAGAR Locality
City/Town/Village BHOPAL District BHOPAL
State/UT MADHYA PRADESH Pin Code 462003
Email Address erc*************@gmail.com Mobile Number (+91) 982****025
Land Line No. with --
STD code or any
other Contact No.

Fee Payment Details

Payment Mode: Pay through PAYTM Transaction ID: 20190926111212800110168738089589
642
Exam Fee: 650 /- Date of Transaction: 26/09/2019 12:00:00
Fee Submitted On: 26/09/2019
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

IP Address : 157.34.117.55 Date of Downloading : 26/09/2019 12:06:03 PM