01/01/2016

AIPMT2016:ConfirmationPageforApplicationNumber:7404017

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CONFIRMATIONPAGEAIPMT2016
Application/RegistrationNo.

7404017

YouhavesuccessfullysubmittedOnlineApplication.Pleasepreservethispagealongwithproofoffeepaymentforfuturereference.
Candidate'sName

SOUMYAMANDAL

DateofBirth

29/12/1997

Mother'sName

CHAITALIMANDAL

Gender

Male

Father'sName

RASHBEHARIMANDAL

Category

UR

YearofPassing/AppearingClass
XII

2016

PersonwithDisability

No

State/CountrytowhichApplicant
belongs

WestBengal

Nationality

Indian

QuestionPaperMedium

English

ClassXIIMarks(%)

MobileNo.

919531672078

EmailId

sucheta.gcetts@gmail.com

ChoiceofExamCentres

(1)KOLKATA(650)

(2)BHUBANESHWAR(634)

(3)BOKARO(616)

(1)1stState:NA

(2)2ndState:NA

(3)3rdState:NA

(4)ALLIndia:Yes/(UR)

(5)ParticipatingUNIV./INST.:
(6)AFMC:Yes
Yes

OptionForSeats/EligibleCategory

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 is correct. I have not concealed any information. However, if any information furnished herein is found fraudulent,
incorrectoruntrue,IunderstandthatIwillbeliableforcriminalprosecutionandIalsoagreetoforego my candidature/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
Information Bulletin for AIPMT2016 which I have gone through carefully. I further declare that I have not submitted any other application for AIPMT
2016andmobilenoandemailaddressgivenintheformarecorrectandmyownorofmyparents'.

Signature

RightHandIndexFingerImpression

Photo
Completemailingaddress:
Address

C/ORASHBEHARIMANDAL,POSTOFFICEGENDERPUKUR

City

GANDERPUKURSINGUR

State/Country

WestBengal

PinCode

712409

DetailsofTransaction(HDFCBank).
TransactionID.:196354180

Amount(ServiceTaxExtra):1400

DateofTransaction:1/1/201611:49:32AM

CardType:VISA/MasterCard

RegistrationNo:

7404017

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

PrintedOn:01/01/2016

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