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[{"$nulls":4},"平成　　　年　　　月　　　日"]
["公益財団法人　こころのバリアフリー研究会　入会申込書"]
["（ふりがな）　　　　　氏名"]
["所属",null,null,"肩書"]
["連絡先","〒"]
[]
[null,"電話番号",null,"ファックス番号"]
[null,"e-mail"]
[null,null,"＊会からの連絡は基本的にメールで行わせて頂きます。（携帯アドレスは不可）"]
["推薦者\n紹介者"]
[]
["* 推薦者、紹介者（こころのバリアフリー研究会の会員に限る）がいない場合は事務局までお問い合わせ下さい。"]
[]
[]
["【お問い合わせ/連絡先】",null,null," "]
[]
["公益財団法人　"]
["こころのバリアフリー研究会"]
["事務局"]
[]
["〒141-8625"]
["東京都品川区東五反田5-9-22"]
["ＮＴＴ東日本関東病院"]
["精神神経科内"]
["TEL","03-3448-6508"]
["FAX","03-3448-6507"]
["E-mail","jsebmh2013@gmail.com"]

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