11/21/11

AIEEE-2012: Confirmation Page for Application Number :20083078

Sea ch
Click He e o P in Thi Page Clo e

CONFIRMATION PAGE - AIEEE 2012

Mode of E amina ion fo BTech: Offline E am (Pen & Pape Mode) Mode of E amina ion fo BA ch: Offline E am (Pen & Pape Mode)
Regi a ion No. 20083078

You have successfully submitted Application On-line. Kindly take the printout of this page. Paste your two recent photographs and sign in the specified box. Send this form along with original Demand Draft (if fee paid by Demand Draft) to The Join S ec e a (AIEEE Uni ), CBS E, PS 1-2,In i ional A ea, IP E en ion, Pa pa ganj, Delhi 110 092 to reach latest by 5-01-2012. Candidate's Name NAMAN BALI Date of Birth 10/02/1995 M other's Name S HALINI BALI Gender Male Father's Name DEEPAK BALI Category Gene al State of Eligibility CHATTIS GARH ( 07) Person with Disability No Question Paper M edium Engli h Whether Blind Candidate No Year of Passing/Appearing Class XII 2012 Class XII M arks(%) M obile No. 9669919995 Email Id deepak.bali@a an hapo e .com Course Applied Bo h BE / B Tech and B A ch/Planning oge he ( 7) Choice of Exam Centres 1 : RAIPUR ( 211), 2nd : JABALPUR ( 233), 3 d : INDORE ( 234), 4 h : PUNE ( 238)
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 fraudulent, 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 AIEEE Information Bulletin available on website , which I have duly gone through.
Paste (do not staple ) a re ce nt Photograph dul atte ste d b the Principal/He ad of the Institutions / Ga e tte d O ffice r Photograph m ust not be large r than this bo

Paste (do not staple ) a re ce nt unatte ste d Photograph Photograph m ust not be large r than this bo UNA TTESTED

ATTES TED Write here your complete mailing address: Name Address
Left Hand Thumb Impression

City State Country Pin Code

Signature of the Candidate(Not in capital letters) Countersigned by Parent /Guardian ATTESTATION BY HEAD OF THE INSTITUTION/GAZETTED OFFICER

This is to certify that the particulars given in this Application Form including Name, Photograph, Address, Category, Date of Birth and Signature are correct to the best of my knowledge and belief.

aieee.nic.in/aieee2012/aieee/online/ConfirmationPage.asp

1/2

11/21/11

AIEEE-2012: Confirmation Page for Application Number :20083078

Signature of Principal/Head of the Instt./Ga etted Officer Details of Transaction(A is Bank). Transaction ID:
2000034385

ith date and Seal

Amount: 1430.94

Date of Transaction 21/11/2011

Card T pe : Vi a

Registration No

20083078

aieee.nic.in/aieee2012/aieee/online/ConfirmationPage.asp

2/2