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["様式第１号"]
[]
["入 会 申 請 書"]
[]
[]
[]
["全てご記入ください。記入もれがある場合は受理できませんのでご注意ください。"]
["ふりがな"]
[]
["氏　　　名"]
[]
[]
["生年月日",{"$nulls":7}," S ・ H　　　　年　　　月　　　日生",{"$nulls":13},"性　別",{"$nulls":3},"男　・　女"]
[]
[]
["自宅住所",{"$nulls":7},"〒"]
[]
[]
[]
["電話番号",{"$nulls":7},"　（自宅）"]
[]
[{"$nulls":8},"　（携帯）"]
[]
["メールアドレス"]
[]
["薬剤師免許証\n登録番号"]
[]
[{"$nulls":8},"※","薬剤師免許証のコピー（A4サイズ）を添付してください。"]
["登録年月日",{"$nulls":7},"　昭和　・　平成　・　令和　　　　年　　　月　　　日"]
[]
["卒業学校名\n（薬学のみ）",{"$nulls":7},"　（大　学）　　　　　　　　　　　"]
[]
[{"$nulls":8},"　（卒業年月日）　　昭和　・　平成　・　令和　　　　　年　　　　月　　　　日"]
[{"$nulls":8},"　（大学院）　　　　　　　　　　　"]
[]
[{"$nulls":8},"　（卒業年月日）　　昭和　・　平成　・　令和　　　　　年　　　　月　　　　日"]
[]
["沖縄県薬剤師会会長　殿",{"$nulls":28},"令和　　　　　年　　　　月　　　　日"]
[]
[null,"貴会の趣旨に賛同し、入会申請を致します。"]
[]
[{"$nulls":12},"本人署名",{"$nulls":14},"印"]
[]
[]
["受付日",{"$nulls":11},"（代理申請者氏名）",{"$nulls":14},"印"]
[]
[]
[]
[{"$nulls":10},"「入会会員情報登録票」と「薬剤師免許証のコピー」と一緒にご提出ください。ＦＡＸでの受付は行っておりません。"]