NATIONAL ELIGIBILITY CUM ENTRANCE TEST (UG)

CONFIRMATION PAGE - NEET(UG)-2019

You have successfully submitted On-line Application. Please preserve this pagealong withproof of fee payment for future
reference.
Application No. : 190410396242

Candidate's Name ASHWIN BARGAL Date of Birth 27/03/2001

Mother's Name SUSHMA BARGAL Gender Male
Father's Name SOMESH BARGAL Category OBC (NCL)
Year of Passing/Appearing Class 2018 Person with Disability: No
XII
State/Country to which Applicant Madhya Pradesh Nationality Indian
belongs
Question Paper Medium English Class XII Marks(%) 86.4
Mobile No. 91xxxxxx4241 Email Id asxxxxxxxx@gmail.com
Choice of Exam Cities
INDORE ( 3003) UJJAIN ( 3005) BHOPAL ( 3001) AHMEDABAD ( 2201)

DECLARATION :- I hereby solemnly and sincerely affirm that all the particulars stated by me in the Application Form are
true and correct. Even the spelling of names and category are also correct. I have not concealed any information
including information about previous attempts in AIPMT/NEET. However, if any information furnished herein is found
fraudulent, incorrect or untrue, I understand that I will be liable for criminal prosecution which will result incancellation of
my candidature. 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 Information Bulletin for NEET, 2019 which I have
gone through carefully. I further declare that I have not submitted any other application for NEET, 2019 and mobile no
and email address given in the form are correct and my own or of my parents.

Photo Signature
Complete Mailing Address
Address 14, VIVEKANANDA COLONY, CITY POLICE STATION
City JAORA ,RATLAM
State/Country Madhya Pradesh Pin Code 457226
Details of Transaction(SBI Bank)
Transaction ID.: CPK7956182 Total Amount: 1400 Date of Transaction: 11/10/2018 3:19:14 PM
Card Type: VISA/Master Card
Application No: 190410396242 Printed On : 10/11/2018 03:19:22
Note : - Kindly check following details in Confirmation Page :
Candidate’s Name, Mother’s Name, Father’ s Name, Date of Birth, Gender, Category, PwD, Choice of Examination Cities
and Medium of Question Paper. In case of any discrepancy, these may please be corrected during 14th January, 2019 to
31st January, 2019. No corrections shall be allowed under any circumstances after this date.