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["一般財団法人食品環境検査協会 殿",{"$nulls":13},"試 験 検 査 申 込 書",{"$nulls":19},"（太枠 －－ 内をご記入下さい）"]
["  下記の通り試験を依頼します。",{"$nulls":33},"申込日："]
["〔コード〕","依頼者名",null,"（貴社名及びご担当者名を記入して下さい）",{"$nulls":24},"部課名",{"$nulls":8},"担当者名"]
[]
[null,"住  所",null,"〒",{"$nulls":31},"TEL"]
[{"$nulls":35},"FAX"]
["〔コード〕","証明書宛先※１",{"$nulls":4},"□",null,"；依頼者名に同じ　",{"$nulls":8},"□",null,"；依頼者名と異なる（下の[宛先]欄に社名を記入してください）"]
[null,"[宛  先]"]
[]
["〔コード〕","料金請求先",{"$nulls":4},"□",null,"；依頼者名に同じ　",{"$nulls":8},"□",null,"；依頼者名と異なる（下の[請求先]欄に記入してください）"]
[null,"[請求先]",{"$nulls":26},"部課名",{"$nulls":8},"担当者名"]
[null," 住  所",null,"〒",{"$nulls":31},"TEL"]
[{"$nulls":35},"FAX"]
["〔コード〕","証明書送付先",{"$nulls":4},"□",null,"；依頼者名に同じ　",{"$nulls":8},"□",null,"；依頼者名と異なる（下の[送付先]欄に記入してください）"]
[null,"[送付先]",{"$nulls":26},"部課名",{"$nulls":8},"担当者名"]
[null," 住  所",null,"〒",{"$nulls":31},"TEL",{"$nulls":4},"      \n"]
[{"$nulls":35},"FAX"]
["証  明  書",null," 普通 ・ 割増至急",{"$nulls":11},"月",{"$nulls":4},"日",null,null,"証明書発行方法",{"$nulls":7},"和文・英文 （",{"$nulls":4},1,"通） 品目別 ・項目別 ・一括"]
["発行希望日",null,"（割増至急の場合料金は5割増以上となります）",{"$nulls":19},"（結果の連絡）",{"$nulls":7},"  来所 ・ 郵送　（ FAX ・ TEL )"]
["No.","品名（証明書に記載の品名となります。）",{"$nulls":16},"検体数\n(個数）",null,null,null,"  証明書に付記する事項",{"$nulls":12},"(内容によっては記載できない場合がありますのでご了解ください。)"]
[]
[{"$nulls":37},"検体の特徴"]
[{"$nulls":18},"(",null,null,")"]
[{"$nulls":37},"種類：食品、器具、容器包装、添加物、飼料、肥料\nその他〔          〕"]
[{"$nulls":18},"(",null,null,")"]
[]
[{"$nulls":18},"(",null,null,")"]
[{"$nulls":37},"形態：バルク、ポリ袋、缶、瓶、トレイ、ドラム、箱\nその他〔            〕"]
[{"$nulls":18},"(",null,null,")"]
[]
[{"$nulls":18},"(",null,null,")"]
["試 験 項 目",null,null," 試 験 結 果   試験方法（   ） ： 検出限界〔   〕",{"$nulls":29},"手数料コード",null,null,null,"料         金"]
[{"$nulls":37},"（単価×検体数）"]
[]
[]
[]
[]
[]
[]
["依 頼\n目 的","輸出時の品質保証・自社の品質管理・官公庁に提出･\n税関に提出・クレーム処理・栄養表示・JAS関連・\nその他（            　　    　　　　　　　   ）\n",{"$nulls":17},"特  別\n料  金",null,null,null,"×",{"$nulls":8},"手数料小計\n（消費税を除く）"]
[]
[{"$nulls":19},"証明書発行料",null,null,null,"コード〔        〕",{"$nulls":8},"消 費 税 額"]
[]
["試験実施時の指示事項",{"$nulls":18},"出張費",null,null,null,"コード〔        〕",{"$nulls":8},"合 計 金 額"]
[{"$nulls":32},"（消費税を含む）"]
[{"$nulls":19},"試  料\n購入代",null,null,null,"コード〔        〕",{"$nulls":8},"PCﾚｲｱｳﾄNo."]
[{"$nulls":32},"Word作成"]
["検体の保存条件：室温  ・  冷蔵  ・  冷凍"]
["[試験区分]","3.官公庁（課）4.官公庁〔非）5.食品等 6.飼料検定 7.飼料検査 8.環境 9.JAS関連",{"$nulls":31},"受付年月日",null,null,null,"    年     月　　 日"]
["受付","受付\n確認","試験結果記載の確認",{"$nulls":9},"試験結果\n確   認",{"$nulls":4},"証明書\n作  成",{"$nulls":4},"証明書\n確  認",{"$nulls":4},"決裁",{"$nulls":5},"証明書発行日",null,null,null,"    年     月　 　日"]
[{"$nulls":33}," 受付（証明書）No."]
[{"$nulls":33},"　　　　　　　　　　　　　　　号　"]
[]
[]
["※1.証明書上部の「依頼者名」に記載する社名となります。英文証明書が必要な場合は英名を併記して下さい。"]
["  2.証明書発行後は、原則として証明書の依頼者名、品名の変更は出来ません。"]
["  3.証明書の再発行は、発行後1年以内に限ります。"]
["  4.提出された検体は､原則として返却できません。特に返却が必要な場合は受付時にご相談ください。"]