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["獣医学術学会北海道地区学会発表申込書"]
["該当する学会に〇印",{"$nulls":6},"産業動物獣医学会",{"$nulls":8},"太枠のみご記入ください。"]
[]
[{"$nulls":7},"小動物獣医学会"]
[{"$nulls":16},"※欄には記入しないでください"]
[{"$nulls":7},"獣医公衆衛生学会"]
[]
["※","演題番号",{"$nulls":3},"演題名："]
[]
[]
[]
["（",null,null,"）","動画利用ＰＣ持込み",{"$nulls":9},"※動画利用者は、自身のＰＣ持込といたしますので、左記に〇を付けて下さい。"]
[]
["発表者は以下名簿のトップにご記入ください。共同研究者（全員分）はその次に続けて下さい。書ききれない場合は２枚目にご記入下さい。記入漏れの無いようにお願いします。　　　　　　　　　　　　　　　　発表者が会員ではない場合、次のいずれか（番号）を下記の発表者所属支部欄に記載して下さい。"]
[]
[]
["①",null,"獣医学生",null,null,"②",null,"院生・研究生（獣医師）",{"$nulls":10},"③",null,"動物看護学生",{"$nulls":6},"④",null,"一般（研修医含む）"]
["フリガナ"]
[]
["氏名"]
[]
["所属支部",{"$nulls":10},"支部",{"$nulls":8},"支部",{"$nulls":8},"支部",{"$nulls":8},"支部"]
[]
["フリガナ"]
[]
["氏名"]
[]
["所属支部",{"$nulls":10},"支部",{"$nulls":8},"支部",{"$nulls":8},"支部",{"$nulls":8},"支部"]
[]
["発表者所属が、会員以外で①②③の場合、研究室および指導教員（責任者）名を記載"]
["研究室名：",{"$nulls":19},"指導教員（責任者）名："]
[]
["申込者（発表者）連絡先　　連絡先が所属・勤務先の場合は、必ずその名称もご記入下さい"]
["住所",null,null,"〒",{"$nulls":5},"―"]
[]
[]
[]
["所属・勤務先名",{"$nulls":27},"ＴＥＬ"]
[]
[]
["Ｅ－ＭＡＩＬ"]
[]
[]
["氏　名",{"$nulls":19},"携帯番号",{"$nulls":8},"―",{"$nulls":5},"―"]
[]
[]
["地区獣医師会受付",{"$nulls":10},"平成",{"$nulls":4},"年",{"$nulls":3},"月",{"$nulls":3},"日",null,"登録の確認",{"$nulls":6},"会員の確認"]
[]
["北海道獣医師会本部受付",{"$nulls":10},"平成",{"$nulls":4},"年",{"$nulls":3},"月",{"$nulls":3},"日"]

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