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["和歌山県理学療法士協会\n事業参加申込書"]
["事業名","平成27年度 第4回紀南地域局研修会・親睦会"]
["日時","平成28年1月9日（土）　受付 12：30　　　13：00～１8：00　　　　　　　　　"]
["申込先","新宮市立医療センター　リハビリテーション科　西畑将史"]
["申込方法","必要事項を記入し、①②に参加・不参加を○×で記入の上、施設単位で下記までメール添付にて送信下さい。メールアドレス　　miru@hsp.shingu.wakayama.jp\nなお、メール件名は「20160109　平成27年度 第4回紀南地域局研修会（施設名）」でお願いします。　　　　　　　　　　\n個人情報保護や確実な伝達・入力ミス防止の観点から、メールでのお申込みをお願い致します。\nやむを得ずFAX送信される施設は、この用紙に入力し印刷の上、送信して下さい。\n入力ミス軽減のため手書きでの入力はご遠慮下さい。\nFAX　:　0735-31-3337　"]
["締め切り","平成27年12月24日（木）　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　"]
[]
["施設名"]
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["会員番号　半角8ケタ","姓","名","（全角カタカナ）",null,"性別","生年月日","どちらかに○",null,null,"参加項目に○"]
[null,null,null,"姓　　　　　フリガナ","名　　　　　フリガナ",null,null,"新プロ対象者","新プロ未終了","生涯対象者","①研修会","②親睦会"]
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["通信欄"]

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