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["群馬労働局長登録教習機関"]
["一般社団法人 日本クレーン協会"]
[null,"群  馬  支  部"]
[]
[{"$nulls":6},"（切り離さずにＦＡＸして下さい）"]
[]
["(一社)日本クレーン協会 群馬支部   御中"]
["[所在地：〒371-0233 群馬県前橋市横沢町610番地  TEL 027-283-1671  FAX 027-283-8531]"]
["下記の者、      名 申し込みます。"]
["  　　　年     月     日"]
[]
["移動式クレーン運転士安全衛生教育講習申込書"]
[{"$nulls":5},"受講日  　 　年　　月　　日"]
["所在地","（〒           -                ）"]
[]
["事業所名",{"$nulls":5},"該当に○印をつけて下さい","会員 ・ 非会員"]
["担当者",null,null,null,"電話番号"]
["※印の箇所は記入不要"]
["受講番号","ふりがな","生年月日",null,"現　住　所\n（県名のみ）",null,"運転士免許証\n技能講習修了証",null,null," 旧姓等の併記の希望及び\n 旧姓等　希望あり □\n 希望の場合は□にレ点"]
[null,"受講者氏名"]
["※",null,"Ｈ","・     ・",null,"都道        府県","取得","年月日",null," 旧姓等"]
[{"$nulls":6},"交付局（県名）",null,"県"]
[null,null,"Ｓ",null,null,null,"番号  第","号"]
["※",null,"Ｈ","・     ・",null,"都道        府県","取得","年月日",null," 旧姓等"]
[{"$nulls":6},"交付局（県名）",null,"県"]
[null,null,"Ｓ",null,null,null,"番号  第","号"]
["※",null,"Ｈ","・     ・",null,"都道        府県","取得","年月日",null," 旧姓等"]
[{"$nulls":6},"交付局（県名）",null,"県"]
[null,null,"Ｓ",null,null,null,"番号  第","号"]
["※",null,"Ｈ","・     ・",null,"都道        府県","取得","年月日",null," 旧姓等"]
[{"$nulls":6},"交付局（県名）",null,"県"]
[null,null,"Ｓ",null,null,null,"番号  第","号"]
[" ❖旧姓等の併記を希望された方は、戸籍抄本のほか、住民票 （「旧氏」欄に旧姓等が記載されたものに限る） の\n    写し等の提出をお願いいたします。   ※必ず申込時に提出のこと"]
["※移動式クレーン運転士免許証又は小型移動式ｸﾚｰﾝ技能講習修了証の写しを一緒にお送りください。"]
["  ◆振込先◆（振込手数料は、申込者負担でお願い致します。）",{"$nulls":6},"済","日付"]
[" ・銀行口座  群馬銀行 本店営業部 普通 ０６２２５１７",{"$nulls":5},"※受講票",null,"／"]
["  [口座名：(一社)日本クレーン協会群馬支部長 堀口廣政]",{"$nulls":5},"※受講料",null,"／"]
[{"$nulls":6},"※テキスト",null,"／"]
[{"$nulls":6},"※印の箇所は記入不要です。"]
[]
[" ◇入金方法◇　　ａ：銀行　　　ｂ：当協会に持参\n　\n ※右枠内へ該当記号と入金予定日を入れてください。\n    受講料は受講日の１０日前までにお願いいたします。　",{"$nulls":4},"入金\n方法","入金\n予定日"]