12/19/13

AIPMT- 2014: Confirmation Page for Application Number :5310975

CENTRAL BOARD OF SECONDARY EDUCATION

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CONFIRMATION PAGE - AIPMT- 2014

Application / Registration No.

5310975

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-C hallan (if fee paid by E-C hallan) 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 C andidate's Name Mother's Name Father's Name Year of Passing/Appearing C lass XII State /C ountry to which Applicant belongs Question Paper Medium Mobile No. C hoice of Exam C entres Option For Seats/Eligible C ategory
MOIRA NSHA NG N HONGSHA LHINGNEINENG CHONGLOI H TONGIN MA RING 2012 Manipur English +91-8794542781 (1) IMPHA L ( 829) (1) 1st State : Manipur/ ( ST ) (4) A LL India: Yes /( ST )

Date of Birth Gender C ategory Person with Disability Nationality C lass XII Marks(%) Email Id
(2) SHILLONG ( 830) (2) 2nd State : NA

12/02/1995 Female ST No Indian 72 laljaseh.kipgen@gmail.com (3) GUWA HA TI ( 803) (3) 3rd 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 re ce nt Photograph and get it A TTESTED BY HEA D OF THE INSTITUTION / GA ZETTED OFFICER Photograph m ust not be large r than this box

Le ft Hand Thum b Im pre ssion

Signature of the C andidate (Not in capital le tte rs)

Complete mailing address: Address C ity State /C ountry MANIPUR UNIVERSITY C AMPUS STAFF QUARTER NEAR MENS HOSTEL, C ANC HIPUR IMPHAL Manipur Pin C ode 795003
C ounte rsigne d by Pare nt /Guardian

Details of Transaction. Transaction ID:0000000015 Amount:550 Date of Deposit :19/12/2013 Fee Transaction Updated On:19/12/2013

Bank/Post Office Name :Post office Bank/Post Office Name & Address:MANIPUR UNIVERSITY, MANIPUR, Manipur

ATTESTATION BY HEAD OF THE INSTITUTION/GAZETTED OFFICER This is to certify that the particulars given in this C ONFIRMATION PAGE including Name, Photograph, Address, C ategory, Date of Birth, State C ode of eligibility and Signature are correct to the best of my knowledge and belief.

Signature of Principal/He ad of the Instt./Gaze tte d O ffice r with date and Se al

Name of Attesting Authority Address of Attesting Authority

Tel.No. Mobile No. Date

Registration No:

5310975

Printed On : 19/12/2013

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