AIPMT- 2014: Confirmation Page for Application Number :5519388

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CENTRAL BOARD OF SECONDARY EDUCATION

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CONFIRMATION PAGE - AIPMT- 2014

Application / Registration No.

5519388

You have successfully submitted Application On-line. Kindly take the printout of this page. Paste your recent photograph and sign in the specified box. Send this form along with original E-Challan (if fee paid by E-Challan) to The Assistant Secretary (AIPMT), Central Board of Secoundary Education, Shiksha Kendra, 2, Community Centre, Preet Vihar, Delhi 110 092 to reach latest by 10-01-2014 Candidate's Name Mother's Name Father's Name
RANE RUTUJA NHANU SUNITA NHANU

Date of Birth Gender Category Person with Disability Nationality Class XII Marks(%) Email Id
(2) AHMEDABAD ( 810) (2) 2nd State : NA

16/09/1996 Female UR No Indian sandu_4242@rediffmail.com (3) PANAJI ( 809) (3) 3rd State : NA

Year of Passing/Appearing Class XII 2014 State /Country to which Applicant belongs Question Paper Medium Mobile No. Choice of Exam Centres Option For Seats/Eligible Category
(4) ALL India: Yes /( UR ) Maharashtra English +91-9702890393 (1) MUMBAI ( 827) (1) 1st State : NA

(5) Participating UNIV./INST. : Yes

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 fradaulent, 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 - 2014 Information Bulletin available on website, which I have duly gone through. I further declare that I have not submitted any other application for AIPMT-2014.

Paste (do not staple) a recent Photograph and get it ATTESTED BY HEAD OF THE INSTITUTION / GAZETTED OFFICER Photograph must not be larger than this box Left Hand Thumb Impression

Signature of the Candidate(Not in capital letters)

Complete mailing address: Address City ROOM NO.3 HARISHCHANDRA KENI CHL TRIMURTI SOC. DNYANESHWAR NGR. S N DUBE ROAD RAWALPADA, DAHISAR EAST MUMBAI Pin Code 400068
Countersigned by Parent /Guardian

State /Country Maharashtra

Details of Transaction(Syndicate Bank). Transaction ID.: MHCC3208156715 Card Type : VISA/Master Card ATTESTATION BY HEAD OF THE INSTITUTION/GAZETTED OFFICER This is to certify that the particulars given in this CONFIRMATION PAGE including Name, Photograph, Address, Category, Date of Birth, State Code of eligibility and Signature are correct to the best of my knowledge and belief. Amount(Service Tax Extra): 1000 Date of Transaction 12/28/2013 10:59:12 AM

Signature of Principal/Head of the Instt./Gazetted Officer with date and Seal

Name of Attesting Authority Address of Attesting Authority

Tel.No. Mobile No. Date

http://aipmt.nic.in/aipmt/Online/ConfirmationPage.aspx

12/28/2013

AIPMT- 2014: Confirmation Page for Application Number :5519388

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Registration No:

5519388

Printed On : 28/12/2013

http://aipmt.nic.in/aipmt/Online/ConfirmationPage.aspx

12/28/2013