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["日本産婦人科・新生児血液学会　入会申し込書\n（賛助会員）"]
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["年　　　　月　　　　日　　　　　"]
["所属機関"]
["機関名"]
["部署名"]
["住　所","〒（　　　　　－　　　　　　）"]
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["ＴＥＬ",null,"ＦＡＸ"]
["代表者名",null,null,null,"役　職"]
["ご担当者"]
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["Ｅ－ｍａｉｌ","＠"]
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["年会費納入額",null,"　　金　　　　　　　　　　　　円"]
["年会費納入方法",null,"□銀行振り込み　　　□郵便振替　　　その他（　　　　　　　　　　　　　　　）"]
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["入会申し込書　送付先・問合せ先"]
["住　所","〒807-8555　　\n北九州市八幡西区医生ケ丘1-1　\n産業医科大学小児科学教室内　　\n日本産婦人科・新生児血液学会　事務局　宛",null,null,"ＴＥＬ","０９３－６９１－７２５４"]
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