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[]
[null,"(様式第１号)"]
[null,"　　　　 ",null,null,"NPO法人　栃木県車椅子の会"]
[]
[null,null,"　　　　　　　　入 　会 　申　 込　 書"]
[]
[]
[null,"会　長　殿"]
[]
[null,"申　込　日","平成　　年　　月　　日",null,null,"会員種別","　正会員　","　"]
[null,"フリガナ",null,"　",null,"生年月日","　　　　　　　　年　　月　　日"]
[null,"氏名","　　",null,null,"性　　別","男　・　女","(　　　　　　才)"]
[{"$nulls":5},"受傷年月","　"]
[]
[null,"住所","〒"]
[]
[]
[null,null," TEL..　(           )          － "]
[null,null," TEL..　(           )          － "]
[null,null," E-Mail:"]
[]
[null,"　",null,"以下は任意で記入　(いずれかをチェック)　して下さい"]
[null,"傷　病　名","　□頚損　　□胸損　　□腰損　　□脊髄疾病　　□ポリオ　□小児マヒ"]
[null,null,"　□筋ジス　　□その他(　　　　　　　　)"]
[null,null,"　・身障手帳等級(　　級)"]
[null,"傷 病 原 因","　□疾病　□労災事故　□交通事故　□その他"]
[null,"受 給 年 金","　□労災傷病　□労災障害　□障害厚生　□障害基礎　□障害共済　□無年金"]
[null,"就 労 状 況","　□勤務している　　□勤務していない"]
[null,"自動車免許","　□持っている　　　□持っていない"]
[]
[null,"　(ご意見等)"]
[]
[]
[null,"　　【申込者(会員番号　　　　　　　)の入会を許可します。"]
[null,null,null,"　　　　　　栃木県車椅子の会　会長　　　村上八郎　　　　"]

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