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["様式第４号"]
["埼玉県がん検診受診促進宣言事業所 登録辞退届"]
[]
[null,null,null,null,null,null,"令和　　年　　月　　日"]
[]
["■１．登録情報（記入日時点の情報を入力してください。）"]
["１．登録番号"]
["２．法人名/事業所名",null,"※支店名で登録している場合は支店名を含め記入してください。"]
[null,null,"フリガナ"]
[null,null,"法人名\n事業所名"]
["３．連絡先",null,"電話番号　　（　　　　　　　-　　　　　　　-　　　　　　　　）"]
[null,null,"メールアドレス"]
["４．担当者氏名",null,"フリガナ"]
[null,null,"氏名"]
[]
["■２．その他"]
["１．備考欄"]