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[]
[null,"施術管理者の届出（申出）について（各種手続き一覧早見表）"]
[null,null,null,"確約書\n様式第１号","施術所\n届出書\n様式第２号","同意書\n（勤務者追加等）\n様式第２号の２","誓約書\n様式第２号の３","変更届出書\n様式第４号","※１\n施術管理者\n選任証明","※２\n免許証\n（写）","※３\n開設届\n（写）","※３\n廃止届\n（写）","※３\n変更届\n（写）","※５\n勤務形態\n確認票","※６\n欠格事由\nに該当\nしない旨\nの申出書","実務経験\n期間証明書\n（写）","施術管理者\n研修修了証\n（写）","その他"]
[null,null,null,null,null,null,null,null,null,null,"保健所（交付）"]
[null,1,"受領委任を新たに取り扱うとき","○","○","△","○","-","△","○","○","-","-","○","△","○","○","-"]
[null,2,"施術管理者が変更したとき","○","○","△","○","○","△","○","△","-","△","○","△","※７\n○","※７\n○","-"]
[null,3,"新たに柔道整復師を雇用したとき\n又は勤務柔道整復師が退職したとき","-","-","△\n雇用のみ","-","○","-","△\n雇用のみ","-","-","○","-","-","-","-","-"]
[null,4,"開設者のみ変更があったとき","-","-","-","○","○","△","-","○","○","-","-","-","-","-","-"]
[null,5,"施術所の名称、電話番号等を\n変更したとき","-","-","-","-","○","-","-","-","-","○","-","-","-","-","-"]
[null,6,"※４\n施術所の所在地を変更したとき","○","○","△","○","○","△","○","○","○","-","○","△","※８\n○","※８\n○","-"]
[null,7,"施術管理者の氏名を変更したとき","-","-","-","-","○","-","○\n変更後","-","-","○","-","-","-","-","-"]
[null,8,"施術所を廃止したとき","-","-","-","-","○","-","-","-","○","-","-","-","-","-","-"]
[null,9,"施術管理者が死亡したとき","-","-","-","-","○","-","-","-","-","-","-","-","-","-","死亡の確認できる書類\n（住民票除票・\n死亡診断書など）"]
[]
[null,"○・・・必要なもの　　　△・・・いずれか該当する場合に必要なもの"]
[null,"※１　開設者が管理者以外の人（管理者が代表を務める法人に変わる場合も含む。）に変更するときは必要だが、開設者が管理者本人に変わる場合は不要。"]
[null,"※２　申請書類の様式第２号の２を申請する場合は、その勤務柔道整復師の免許証の写しを合わせて添付すること。"]
[null,"※３　保健所が交付したものの写しを添付すること。申請内容によって、保健所が交付するものが異なるので注意すること。"]
[null,"※４　施術所の移転は、旧施術所の廃止年月日と新施術所の開設年月日の間が概ね２週間以内であること。また、２週間以内に北海道厚生局へ届け出ること。"]
[null,"条件を満たさない場合、受領委任の登録年月日（受領委任の取扱いの開始日）は、新規の届出と同様に、北海道厚生局への届出年月日となるので注意すること。"]
[null,"※５　複数の施術所の施術管理者となる場合は添付すること。"]
[null,"※６　受領委任の登録又は承諾にあたり、北海道厚生局長又は北海道知事からの求めがあった場合に添付すること。"]
[null,"※７　新たに受領委任の取扱いを行う施術管理者となる者について添付すること。"]
[null,"※８　新たに受領委任の取扱いを行う施術管理者となる者について添付すること。施術管理者としての継続性がある場合は、添付不要。"]

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[]
[]
[]
[null,null,"（様式第１号）"]
[]
[]
["確　　　　約　　　　書"]
[]
[]
[]
[]
[]
[]
[null,null,"　柔道整復師の施術に係る療養費の受領委任の取扱いを申し出るに当たり、受"]
[]
[null,null,"領委任の取扱規程（平成２２年５月２４日保発0524第２号通知別添２）を遵守"]
[]
[null,null,"することを確約します。"]
[]
[]
[]
[]
[]
[null,null,null,"令和",null,null,null,"年",null,null,null,"月",null,null,null,"日"]
[]
[]
[]
[]
[null,null,null,null,"北海道厚生局長"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"殿"]
[]
[null,null,null,null,"北海道知事"]
[]
[]
[]
[]
[]
[null,null,null,null,null,null,"柔道整復師氏名"]
[]
[]
[null,null,null,null,null,null,"住所",null,null,null,null,null,null,null,"〒"]
[]
[]
[]
[]
[null,null,null,null,null,null,"（受領委任の取扱いを行う施術所）"]
[]
[null,null,null,null,null,null,"施術所名"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,"〒",null,null,null,null,null,null,"TEL."]
[null,null,null,null,null,null,"住　所"]

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[]
[]
["（様式第２号）"]
["柔道整復施術療養費の受領委任の取扱いに係る申し出（施術所の申し出）"]
[]
["柔道整復師\n（受領委任の\n施術管理者）",null,null,null,null,null,"第\n１","ふりがな"]
[null,null,null,null,null,null,null,"氏名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"大・昭・平・令",null,null,null,null,null,null,null,"年",null,null,"月",null,null,"日","生"]
[]
[]
[null,null,null,null,null,null,null,"免許",null,null,null,null,null,"番号",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（取得年月日）",null,null,null,null,null,"大・昭・平・令",null,null,null,null,null,null,null,"年",null,null,"月",null,null,"日"]
["施　術　所",null,null,null,null,null,null,"ふりがな"]
[null,null,null,null,null,null,null,"名称"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（電話番号：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,null,null,null,null,null,null,"所在地",null,null,null,null,null,"〒"]
[]
[]
[null,null,null,null,null,null,null,"ふりがな",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"住所",null,"〒"]
[null,null,null,null,null,null,null,"開設者\n氏名及び\n住所",null,null,null,null,null,"氏名"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"大・昭・平・令",null,null,null,null,null,null,"年",null,null,"月",null,null,"日","生"]
["申し出前５年間における受領委任の\n取扱いの中止",null,null,null,null,null,null,null,null,null,null,null,null,"有 ・ 無",null,null,null,null,null,"中止年月日"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"当該地方厚生(支)局長等"]
["柔道整復師の施術に係る療養費の算定基準の備考５に基づく施術所の届出",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"定額料金の徴収を（　行う・行わない　）"]
["注１　施術所において勤務する他の柔道整復師について、様式第２号の２で申し出ること。"]
["　２　申し出に当たっては、施術所の申し出及び勤務する柔道整復師等の確認できる書類の写し等を添付すること。"]
["　３　施術管理者が複数の施術所において受領委任の取扱いを行う場合は、備考欄に各施術所における勤務形態等を記入すること。"]
["　４　開設者氏名欄は、開設者と施術管理者が同一人の場合は「同上」と記入することとし、住所欄の記入は必要ないこと。"]
["（備考）"]
[]
[]
["上記のとおり、柔道整復施術療養費の受領委任の取扱いについて申し出します。"]
[null,"令和",null,null,null,"年",null,null,"月",null,null,"日"]
[]
["北海道厚生局長"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"殿",null,null,null,null,"柔道整復師氏名"]
["北海道知事"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"〒",null,null,null,null,null,null,null,"TEL."]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"住所"]
[]
["（この申し出は、北海道厚生局へ提出してください。）"]

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[]
[]
["（様式第２号の２）"]
["柔道整復施術療養費の受領委任の取扱いに係る申し出（同意書）"]
[]
[]
["　施術所において勤務する他の柔道整復師として、受領委任の取扱規程（平成２２年５月２４日保発０５２４第２号通知の別添２）の"]
["第３章に定める事項を遵守し、第２章１２及び１５並びに第８章の適用を受けることについて同意します。"]
[]
["施術所に勤務する他の柔道整復師","\n\n第２","ふりがな"]
[null,null,"氏名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"大・昭・平・令",null,null,null,null,null,null,null,"年",null,null,"月",null,null,"日","生"]
[]
[null,null,"免許",null,null,null,null,"番号",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（取得年月日）",null,null,null,null,null,null,"大・昭・平・令",null,null,null,null,null,null,null,"年",null,null,"月",null,null,"日"]
[null,null,"申し出前５年間における受領委任\nの取扱い中止",null,null,null,null,null,null,null,null,null,null,null,null,"有　・　無",null,null,null,null,null,"中止年月日"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"当該地方厚生(支)局長等"]
[null,null,"勤務時間",null,null,null,null,"午前",null,null,null,"時",null,null,"分","～",null,null,null,"時",null,null,"分","（月・火・水・木・金・土・日）"]
[null,null,null,null,null,null,null,"午後",null,null,null,"時",null,null,"分","～",null,null,null,"時",null,null,"分","（月・火・水・木・金・土・日）"]
[null,"\n\n第３","ふりがな"]
[null,null,"氏名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"大・昭・平・令",null,null,null,null,null,null,null,"年",null,null,"月",null,null,"日","生"]
[]
[null,null,"免許",null,null,null,null,"番号",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（取得年月日）",null,null,null,null,null,null,"大・昭・平・令",null,null,null,null,null,null,null,"年",null,null,"月",null,null,"日"]
[null,null,"申し出前５年間における受領委任\nの取扱い中止",null,null,null,null,null,null,null,null,null,null,null,null,"有　・　無",null,null,null,null,null,"中止年月日"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"当該地方厚生(支)局長等"]
[null,null,"勤務時間",null,null,null,null,"午前",null,null,null,"時",null,null,"分","～",null,null,null,"時",null,null,"分","（月・火・水・木・金・土・日）"]
[null,null,null,null,null,null,null,"午後",null,null,null,"時",null,null,"分","～",null,null,null,"時",null,null,"分","（月・火・水・木・金・土・日）"]
[null,"\n\n第４","ふりがな"]
[null,null,"氏名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"大・昭・平・令",null,null,null,null,null,null,null,"年",null,null,"月",null,null,"日","生"]
[]
[null,null,"免許",null,null,null,null,"番号",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（取得年月日）",null,null,null,null,null,null,"大・昭・平・令",null,null,null,null,null,null,null,"年",null,null,"月",null,null,"日"]
[null,null,"申し出前５年間における受領委任\nの取扱い中止",null,null,null,null,null,null,null,null,null,null,null,null,"有　・　無",null,null,null,null,null,"中止年月日"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"当該地方厚生(支)局長等"]
[null,null,"勤務時間",null,null,null,null,"午前",null,null,null,"時",null,null,"分","～",null,null,null,"時",null,null,"分","（月・火・水・木・金・土・日）"]
[null,null,null,null,null,null,null,"午後",null,null,null,"時",null,null,"分","～",null,null,null,"時",null,null,"分","（月・火・水・木・金・土・日）"]
[]
["（注）施術所に勤務する他の柔道整復師は、署名をすること。"]
[]
["（この申し出は、北海道厚生局へ提出してください。）"]

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[]
[]
["（様式第２号の３）"]
["誓　約　書"]
[]
["　私（受領委任の施術管理者及び開設者）は、下記１及び２のいずれにも該当しません。また、将来においても該当することはありません。"]
["　この誓約が虚偽であり、又はこの誓約に反したことにより、当方が不利益を被ることとなっても、異議は一切申し立てません。"]
["　また、当方の個人情報を警察に提供することについて同意します。"]
[]
["記"]
["１　受領委任を取扱う者として不適当な者"]
["　(１)　施術管理者又は開設者が、暴力団(暴力団員による不当な行為の防止等に関する法律(平成３年法律第77号)第２条第２号に規定する暴力団をいう。 以"]
["　　下同じ。)又は暴力団員(同法第２条第６号に規定する暴力団員をいう。以下同じ。)である者"]
["　(２)　施術管理者又は開設者が、自己、自社若しくは第三者の不正の利益を図る目的又は第三者に損害を加える目的をもって、暴力団又は暴力団員を利用す"]
["　　るなどしている者"]
["　(３)　施術管理者又は開設者が、暴力団又は暴力団員に対して、資金等を供給し、又は便宜を供与するなど直接的あるいは積極的に暴力団の維持、運営に協"]
["　　力し、若しくは関与している者"]
["　(４)　施術管理者又は開設者が、暴力団又は暴力団員であることを知りながらこれを不当に利用するなどしている者"]
["　(５)  施術管理者又は開設者が、暴力団又は暴力団員と社会的に非難されるべき関係を有している者"]
[]
["２　受領委任を取扱う者として不適当な行為をする者"]
["　(６)　施術管理者又は開設者が、暴力的な要求行為を行う者"]
["　(７)　施術管理者又は開設者が、法的な責任を超えた不当な要求行為を行う者"]
["　(８)　施術管理者又は開設者が、受領委任の取扱いに関して脅迫的な言動をし、又は暴力を用いる行為を行う者"]
["　(９)　施術管理者又は開設者が、偽計又は威力を用いて受領委任の取扱いの業務を妨害する行為を行う者"]
["　(10)　施術管理者又は開設者が、その他(6)から(9)の各号に準ずる行為を行う者"]
[]
["令和",null,null,null,"年",null,null,null,"月",null,null,null,"日"]
["（フリガナ）"]
["　受領委任の施術管理者氏名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"大・昭・平・令",null,null,null,null,null,null,null,null,"年",null,null,null,"月",null,null,null,"日",null,"生",null,null,"性別：男・女"]
["　住所",null,null,"〒",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"TEL：",null,null,null,null,null,null,"－",null,null,null,null,"－"]
["（フリガナ）"]
["　開設者氏名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"大・昭・平・令",null,null,null,null,null,null,null,null,"年",null,null,null,"月",null,null,null,"日",null,"生",null,null,"性別：男・女"]
["　住所",null,null,"〒",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"TEL：",null,null,null,null,null,null,"－",null,null,null,null,"－"]
[]
[]
[]
["注　開設者氏名は、開設者と施術管理者が同一人の場合は「同上」と記入すること。"]
["（この申し出は、北海道厚生局へ提出してください。）"]

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[]
[]
["（様式第４号）"]
["柔道整復施術療養費の受領委任の取扱いに係る申出事項の変更等"]
[]
["柔道整復師\n（受領委任の\n施術管理者）",null,null,null,null,null,"登録記号番号"]
[null,null,null,null,null,null,"氏名"]
[]
[null,null,null,null,null,null,"施術所名"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（電話番号：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,null,null,null,null,null,"開設者氏名",null,null,null,null,null,"氏名"]
["区分",null,"１　柔道整復師の施術に係る療養費の算定基準の備考５に基づく施術所の届出",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"定額料金の徴収を（　行う・中止　）"]
[]
[null,null,"２その他",null,"変更内容"]
[]
[]
[]
[null,null,null,null,null,null,"（変更年月日：",null,null,null,null,null,"令和",null,null,null,"年",null,null,null,"月",null,null,null,"日",null,"）"]
[null,null,null,null,"理由等"]
[]
[]
[]
[]
["上記のとおり申出事項の変更を申し出します。"]
[null,"令和",null,null,null,"年",null,null,"月",null,null,"日"]
[]
[null,null,"北海道厚生局長"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"殿",null,null,null,null,"柔道整復師名"]
[null,null,"北海道知事"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"住所"]
[]
["（この申し出は、北海道厚生局へ提出してください。）"]
["（注）当該柔道整復師（受領委任の施術管理者）が死亡した場合は、事実が確認できる書類として住民票等の書類を添付"]
["　　し、申出人の氏名及び住所並びに当該柔道整復師との関係を記入すること。"]
["　　　また、施術所において勤務する他の柔道整復師を追加する場合は、様式第２号の２等を添付すること。"]

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[]
[]
["施術管理者選任証明"]
[]
[]
[]
[]
["施術所の「施術管理者」として、下記の柔道整復師を選任したことを証明する。"]
[]
[]
["記"]
[]
[]
[null,null,"施術所名称"]
[]
[]
[]
[]
[null,null,"施術所住所",null,null,null,null,null,null,null,null,"〒"]
[]
[]
[]
[]
[null,null,"施術管理者氏名"]
[]
[]
[]
[]
[null,null,"施術管理者住所",null,null,null,null,null,null,null,null,"〒"]
[]
[]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"令和",null,null,null,"年",null,null,null,"月",null,null,null,"日"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"〒"]
[null,null,null,null,null,null,null,null,null,null,null,"開設者住所"]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,"開設者氏名"]
[]
[]
[]
["　　　　　[記載上の注意]　　開設者と施術管理者が異なる場合に提出してください。"]

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[]
[]
[]
[null,"勤　務　形　態　確　認　票"]
[]
[null,"柔道整復師名",null,null,null,null,null,null,null,null,null,null,"自宅住所"]
[null,"施術所名称"]
[null,"施術所所在地"]
[null,"管理・勤務の区分","管 理　・　勤 務",null,null,null,null,null,null,null,null,null,"管 理　・　勤 務",null,null,null,null,null,null,null,null,null,"管 理　・　勤 務"]
[null,"勤 務 時 間","曜日（",null,null,null,null,null,null,null,"）",null,"曜日（",null,null,null,null,null,null,null,"）",null,"曜日（",null,null,null,null,null,null,null,"）"]
[null,null,"ＡＭ",null,null,"：",null,"～",null,"：",null,null,"ＡＭ",null,null,"：",null,"～",null,"：",null,null,"ＡＭ",null,null,"：",null,"～",null,"："]
[null,null,"ＰＭ",null,null,"：",null,"～",null,"：",null,null,"ＰＭ",null,null,"：",null,"～",null,"：",null,null,"ＰＭ",null,null,"：",null,"～",null,"："]
[null,null,"曜日（",null,null,null,null,null,null,null,"）",null,"曜日（",null,null,null,null,null,null,null,"）",null,"曜日（",null,null,null,null,null,null,null,"）"]
[null,null,"ＡＭ",null,null,"：",null,"～",null,"：",null,null,"ＡＭ",null,null,"：",null,"～",null,"：",null,null,"ＡＭ",null,null,"：",null,"～",null,"："]
[null,null,"ＰＭ",null,null,"：",null,"～",null,"：",null,null,"ＰＭ",null,null,"：",null,"～",null,"：",null,null,"ＰＭ",null,null,"：",null,"～",null,"："]
[null,null,"曜日（",null,null,null,null,null,null,null,"）",null,"曜日（",null,null,null,null,null,null,null,"）",null,"曜日（",null,null,null,null,null,null,null,"）"]
[null,null,"ＡＭ",null,null,"：",null,"～",null,"：",null,null,"ＡＭ",null,null,"：",null,"～",null,"：",null,null,"ＡＭ",null,null,"：",null,"～",null,"："]
[null,null,"ＰＭ",null,null,"：",null,"～",null,"：",null,null,"ＰＭ",null,null,"：",null,"～",null,"：",null,null,"ＰＭ",null,null,"：",null,"～",null,"："]
[null,"休　業　日","日 ・ 月 ・ 火 ・ 水 ・ 木 ・ 金 ・ 土",null,null,null,null,null,null,null,null,null,"日 ・ 月 ・ 火 ・ 水 ・ 木 ・ 金 ・ 土",null,null,null,null,null,null,null,null,null,"日 ・ 月 ・ 火 ・ 水 ・ 木 ・ 金 ・ 土"]
[null,null,"祝祭日　・　振替休日",null,null,null,null,null,null,null,null,null,"祝祭日　・　振替休日",null,null,null,null,null,null,null,null,null,"祝祭日　・　振替休日"]
[null,null,"その他（",null,null,null,null,null,null,null,null,"）","その他（",null,null,null,null,null,null,null,null,"）","その他（",null,null,null,null,null,null,null,null,"）"]
[null,"　同一日に複数の施術所に勤務する必要がある場合の移動手段","①","当初勤務する施術所の住所"]
[null,null,null,"移 動 先 施 術 所 の 住 所"]
[null,null,null,"施　術　所　間　の　距　離",null,null,null,null,null,null,null,null,"（",null,null,null,null,null,null,"）Ｋｍ"]
[null,null,null,"移　　　 動　　　 手　　　 段",null,null,null,null,null,null,null,null,"区　　　　　間",null,null,null,null,null,null,null,null,null,"距　　離　　・　　時　　間"]
[null,null,null,"電車・バス・車・徒歩・その他（",null,null,null,null,null,null,null,"）","（",null,null,"）から（",null,null,null,null,null,"）","（",null,"）Km",null,"（",null,null,"）分"]
[null,null,null,"電車・バス・車・徒歩・その他（",null,null,null,null,null,null,null,"）","（",null,null,"）から（",null,null,null,null,null,"）","（",null,"）Km",null,"（",null,null,"）分"]
[null,null,null,"電車・バス・車・徒歩・その他（",null,null,null,null,null,null,null,"）","（",null,null,"）から（",null,null,null,null,null,"）","（",null,"）Km",null,"（",null,null,"）分"]
[null,null,"②","当初勤務する施術所の住所"]
[null,null,null,"移 動 先 施 術 所 の 住 所"]
[null,null,null,"施　術　所　間　の　距　離",null,null,null,null,null,null,null,null,"（",null,null,null,null,null,null,"）Ｋｍ"]
[null,null,null,"移　　　 動　　　 手　　　 段",null,null,null,null,null,null,null,null,"区　　　　　間",null,null,null,null,null,null,null,null,null,"距　　離　　・　　時　　間"]
[null,null,null,"電車・バス・車・徒歩・その他（",null,null,null,null,null,null,null,"）","（",null,null,"）から（",null,null,null,null,null,"）","（",null,"）Km",null,"（",null,null,"）分"]
[null,null,null,"電車・バス・車・徒歩・その他（",null,null,null,null,null,null,null,"）","（",null,null,"）から（",null,null,null,null,null,"）","（",null,"）Km",null,"（",null,null,"）分"]
[null,null,null,"電車・バス・車・徒歩・その他（",null,null,null,null,null,null,null,"）","（",null,null,"）から（",null,null,null,null,null,"）","（",null,"）Km",null,"（",null,null,"）分"]
[null,null,"③","当初勤務する施術所の住所"]
[null,null,null,"移 動 先 施 術 所 の 住 所"]
[null,null,null,"施　術　所　間　の　距　離",null,null,null,null,null,null,null,null,"（",null,null,null,null,null,null,"）Ｋｍ"]
[null,null,null,"移　　　 動　　　 手　　　 段",null,null,null,null,null,null,null,null,"区　　　　　間",null,null,null,null,null,null,null,null,null,"距　　離　　・　　時　　間"]
[null,null,null,"電車・バス・車・徒歩・その他（",null,null,null,null,null,null,null,"）","（",null,null,"）から（",null,null,null,null,null,"）","（",null,"）Km",null,"（",null,null,"）分"]
[null,null,null,"電車・バス・車・徒歩・その他（",null,null,null,null,null,null,null,"）","（",null,null,"）から（",null,null,null,null,null,"）","（",null,"）Km",null,"（",null,null,"）分"]
[null,null,null,"電車・バス・車・徒歩・その他（",null,null,null,null,null,null,null,"）","（",null,null,"）から（",null,null,null,null,null,"）","（",null,"）Km",null,"（",null,null,"）分"]
[null,"備　　考"]
[]
[null,"※　同一日に複数の施術所に勤務する場合は、それぞれの施術所間の移動手段、移動時間等を記載してください。"]

{"sheet":"実務経験期間証明書","index":8,"n_rows":36,"n_cols":18,"rows_kept":36,"cut":false,"hidden":false,"merged":[[32,8,32,10],[32,11,32,16],[14,16,18,16],[23,8,23,10],[23,11,23,16],[24,11,24,16],[26,11,26,16],[27,8,27,10],[27,11,27,16],[14,14,18,14],[28,11,28,16],[29,11,29,16],[30,11,30,16],[31,8,31,10],[31,11,31,16],[14,1,19,2],[14,4,18,4],[14,6,18,6],[14,8,18,8],[14,12,18,12],[4,1,4,17],[8,1,8,2],[8,3,8,17],[9,1,13,2],[9,4,13,4],[9,6,13,6],[9,8,13,8]]}
[]
[]
["別紙様式１"]
[]
[null,"実 務 経 験 期 間 証 明 書"]
[]
[null,"次の者は当施設において、柔道整復師として実務に従事したことを証明します。"]
[]
[null,"氏　　名"]
[null,"生年月日"]
[null,null,null,"昭　和"]
[null,null,null,"・",null,"年",null,"月",null,"日"]
[null,null,null,"平　成"]
[]
[null,"従事期間",null,"昭　和",null,null,null,null,null,null,null,"昭　和"]
[null,null,null,"・",null,null,null,null,null,null,null,"・"]
[null,null,null,"平　成",null,"年",null,"月",null,"日","～","平　成",null,"年",null,"月",null,"日"]
[null,null,null,"・",null,null,null,null,null,null,null,"・"]
[null,null,null,"令　和",null,null,null,null,null,null,null,"令　和"]
[null,null,null,null,"年",null,"ヵ月"]
[]
[null,"令和",null,"年",null,"月",null,"日"]
[]
[null,null,null,null,null,null,null,null,"施　設　名"]
[]
[null,null,null,null,null,null,null,null,"登録記号番号（又は医療機関コード）"]
[]
[null,null,null,null,null,null,null,null,"所　在　地"]
[]
[null,null,null,null,null,null,null,null,"ＴＥＬ",null,null,"　　　　　－　　　　－"]
[]
[null,null,null,null,null,null,null,null,"管理者職名"]
[null,null,null,null,null,null,null,null,"及び氏名"]
[]
[null,"（注）","１．柔道整復師としての実務経験期間を記載すること。"]
[null,null,"２．虚偽の証明を行ったときは、受領委任の取扱いの中止又は中止相当となります。"]

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[]
[]
[]
[null,null,"（様式第１号）"]
[]
[]
["確　　　　約　　　　書"]
[]
[]
[]
[]
[]
[]
[null,null,"　柔道整復師の施術に係る療養費の受領委任の取扱いを申し出るに当たり、受"]
[]
[null,null,"領委任の取扱規程（平成２２年５月２４日保発0524第２号通知別添２）を遵守"]
[]
[null,null,"することを確約します。"]
[]
[]
[]
[]
[]
[null,null,null,"令和",null,"〇",null,"年",null,"〇",null,"月",null,"〇",null,"日"]
[]
[]
[]
[]
[null,null,null,null,"北海道厚生局長"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"殿"]
[]
[null,null,null,null,"北海道知事"]
[]
[]
[]
[]
[]
[null,null,null,null,null,null,"柔道整復師氏名",null,null,null,null,null,null,null,null,"北海　太郎"]
[]
[]
[null,null,null,null,null,null,"住所",null,null,null,null,null,null,null,"〒","000-0000"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"北海道〇〇市〇〇町1-2-3"]
[]
[]
[]
[null,null,null,null,null,null,"（受領委任の取扱いを行う施術所）"]
[]
[null,null,null,null,null,null,"施術所名",null,null,null,null,"北海道接骨院"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,"〒","123-4567",null,null,null,null,null,"TEL.",null,"000-000-0000"]
[null,null,null,null,null,null,"住　所",null,null,null,null,"北海道〇〇市〇〇町1-1-1"]

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[]
[]
[null,"（様式第２号）"]
[null,"柔道整復施術療養費の受領委任の取扱いに係る申し出（施術所の申し出）"]
[]
[null,"柔道整復師\n（受領委任の\n施術管理者）",null,null,null,null,null,"第\n１","ふりがな",null,null,null,null,null,"ほっかい　たろう"]
[null,null,null,null,null,null,null,null,"氏名",null,null,null,null,null,"北海　太郎",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"大・昭・平・令",null,null,null,null,null,"〇",null,"年","〇",null,"月","〇",null,"日","生"]
[]
[]
[null,null,null,null,null,null,null,null,"免許",null,null,null,null,null,"番号",null,"○○○○○",null,null,null,null,null,null,null,null,null,null,null,null,null,"（取得年月日）",null,null,null,null,null,"大・昭・平・令",null,null,null,null,null,"〇",null,"年","〇",null,"月","〇",null,"日"]
[null,"施術所",null,null,null,null,null,null,"ふりがな",null,null,null,null,null,"ほっかいどうせっこついん"]
[null,null,null,null,null,null,null,null,"名称",null,null,null,null,null,"北海道接骨院"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（電話番号：",null,null,null,"000-000-0000",null,null,null,null,null,null,null,null,null,null,"）"]
[null,null,null,null,null,null,null,null,"所在地",null,null,null,null,null,"〒","123-4567"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"北海道○○市○○町1-1-1"]
[]
[null,null,null,null,null,null,null,null,"ふりがな",null,null,null,null,null,"かぶしきがいしゃ　ほっかいこうせい　だいひょうとりしまりやく　ほっかい はなこ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"住所",null,"〒","987-6543"]
[null,null,null,null,null,null,null,null,"開設者\n氏名及び\n住所",null,null,null,null,null,"氏名",null,"株式会社　北海厚生　\n　　　　代表取締役　北海　花子",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"北海道○○市○○町7-8-9"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"大・昭・平・令",null,null,null,null,"〇",null,"年","〇",null,"月","〇",null,"日","生"]
[null,"申し出前５年間における受領委任の\n取扱いの中止",null,null,null,null,null,null,null,null,null,null,null,null,"有 ・ 無",null,null,null,null,null,"中止年月日"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"当該地方厚生(支)局長等"]
[null,"柔道整復師の施術に係る療養費の算定基準の備考５に基づく施術所の届出",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"定額料金の徴収を（　行う・行わない　）"]
[null,"注１　施術所において勤務する他の柔道整復師について、様式第２号の２で申し出ること。"]
[null,"　２　申し出に当たっては、施術所の申し出及び勤務する柔道整復師等の確認できる書類の写し等を添付すること。"]
[null,"　３　施術管理者が複数の施術所において受領委任の取扱いを行う場合は、備考欄に各施術所における勤務形態等を記入すること。"]
[null,"　４　開設者氏名欄は、開設者と施術管理者が同一人の場合は「同上」と記入することとし、住所欄の記入は必要ないこと。"]
[null,"（備考）",null,null,null,"標榜時間　月火水木金　９：００～１７：００　土　９：００～１２：００　　休日　日祝"]
[]
[]
[null,"上記のとおり、柔道整復施術療養費の受領委任の取扱いについて申し出します。"]
[null,null,"令和",null,"〇",null,"年","〇",null,"月","〇",null,"日"]
[]
[null,"北海道厚生局長"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"殿",null,null,null,null,"柔道整復師氏名",null,null,null,null,null,null,null,"北海　太郎"]
[null,"北海道知事"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"〒","000-0000",null,null,null,null,null,null,"TEL.",null,"000-0000-0000"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"住所",null,null,null,null,null,null,null,"北海道○○市○○町1-2-3"]
[]
[null,"（この申し出は、北海道厚生局へ提出してください。）"]

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[]
[]
[]
["（様式第２号の２）"]
["柔道整復施術療養費の受領委任の取扱いに係る申し出（同意書）"]
[]
[]
["　施術所において勤務する他の柔道整復師として、受領委任の取扱規程（平成２２年５月２４日保発０５２４第２号通知の別添２）の"]
["第３章に定める事項を遵守し、第２章１２及び１５並びに第８章の適用を受けることについて同意します。"]
[]
["施術所に勤務する他の柔道整復師","\n\n第２","ふりがな",null,null,null,null,"ほっかい　じろう"]
[null,null,"氏名",null,null,null,null,"北海　次郎",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"大・昭・平・令",null,null,null,null,null,"〇",null,"年","〇",null,"月","〇",null,"日","生"]
[]
[null,null,"免許",null,null,null,null,"番号",null,"○○○○○○",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（取得年月日）",null,null,null,null,null,null,"大・昭・平・令",null,null,null,null,null,"〇",null,"年","〇",null,"月","〇",null,"日"]
[null,null,"申し出前５年間における受領委任\nの取扱い中止",null,null,null,null,null,null,null,null,null,null,null,null,"有　・　無",null,null,null,null,null,"中止年月日"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"当該地方厚生(支)局長等"]
[null,null,"勤務時間",null,null,null,null,"午前",null,"9",null,"時","00",null,"分","～",null,"12",null,"時","00",null,"分","（月・火・水・木・金・土・日）"]
[null,null,null,null,null,null,null,"午後",null,"13",null,"時","00",null,"分","～",null,"17",null,"時","00",null,"分","（月・火・水・木・金・土・日）"]
[null,"\n\n第３","ふりがな"]
[null,null,"氏名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"大・昭・平・令",null,null,null,null,null,null,null,"年",null,null,"月",null,null,"日","生"]
[]
[null,null,"免許",null,null,null,null,"番号",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（取得年月日）",null,null,null,null,null,null,"大・昭・平・令",null,null,null,null,null,null,null,"年",null,null,"月",null,null,"日"]
[null,null,"申し出前５年間における受領委任\nの取扱い中止",null,null,null,null,null,null,null,null,null,null,null,null,"有　・　無",null,null,null,null,null,"中止年月日"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"当該地方厚生(支)局長等"]
[null,null,"勤務時間",null,null,null,null,"午前",null,null,null,"時",null,null,"分","～",null,null,null,"時",null,null,"分","（月・火・水・木・金・土・日）"]
[null,null,null,null,null,null,null,"午後",null,null,null,"時",null,null,"分","～",null,null,null,"時",null,null,"分","（月・火・水・木・金・土・日）"]
[null,"\n\n第４","ふりがな"]
[null,null,"氏名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"大・昭・平・令",null,null,null,null,null,null,null,"年",null,null,"月",null,null,"日","生"]
[]
[null,null,"免許",null,null,null,null,"番号",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（取得年月日）",null,null,null,null,null,null,"大・昭・平・令",null,null,null,null,null,null,null,"年",null,null,"月",null,null,"日"]
[null,null,"申し出前５年間における受領委任\nの取扱い中止",null,null,null,null,null,null,null,null,null,null,null,null,"有　・　無",null,null,null,null,null,"中止年月日"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"当該地方厚生(支)局長等"]
[null,null,"勤務時間",null,null,null,null,"午前",null,null,null,"時",null,null,"分","～",null,null,null,"時",null,null,"分","（月・火・水・木・金・土・日）"]
[null,null,null,null,null,null,null,"午後",null,null,null,"時",null,null,"分","～",null,null,null,"時",null,null,"分","（月・火・水・木・金・土・日）"]
[]
["（注）施術所に勤務する他の柔道整復師は、署名をすること。"]
[]
["（この申し出は、北海道厚生局へ提出してください。）"]

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[]
[]
["（様式第２号の３）"]
["誓　約　書"]
[]
["　私（受領委任の施術管理者及び開設者）は、下記１及び２のいずれにも該当しません。また、将来においても該当することはありません。"]
["　この誓約が虚偽であり、又はこの誓約に反したことにより、当方が不利益を被ることとなっても、異議は一切申し立てません。"]
["　また、当方の個人情報を警察に提供することについて同意します。"]
[]
["記"]
["１　受領委任を取扱う者として不適当な者"]
["　(１)　施術管理者又は開設者が、暴力団(暴力団員による不当な行為の防止等に関する法律(平成３年法律第77号)第２条第２号に規定する暴力団をいう。 以"]
["　　下同じ。)又は暴力団員(同法第２条第６号に規定する暴力団員をいう。以下同じ。)である者"]
["　(２)　施術管理者又は開設者が、自己、自社若しくは第三者の不正の利益を図る目的又は第三者に損害を加える目的をもって、暴力団又は暴力団員を利用す"]
["　　るなどしている者"]
["　(３)　施術管理者又は開設者が、暴力団又は暴力団員に対して、資金等を供給し、又は便宜を供与するなど直接的あるいは積極的に暴力団の維持、運営に協"]
["　　力し、若しくは関与している者"]
["　(４)　施術管理者又は開設者が、暴力団又は暴力団員であることを知りながらこれを不当に利用するなどしている者"]
["　(５)  施術管理者又は開設者が、暴力団又は暴力団員と社会的に非難されるべき関係を有している者"]
[]
["２　受領委任を取扱う者として不適当な行為をする者"]
["　(６)　施術管理者又は開設者が、暴力的な要求行為を行う者"]
["　(７)　施術管理者又は開設者が、法的な責任を超えた不当な要求行為を行う者"]
["　(８)　施術管理者又は開設者が、受領委任の取扱いに関して脅迫的な言動をし、又は暴力を用いる行為を行う者"]
["　(９)　施術管理者又は開設者が、偽計又は威力を用いて受領委任の取扱いの業務を妨害する行為を行う者"]
["　(10)　施術管理者又は開設者が、その他(6)から(9)の各号に準ずる行為を行う者"]
[]
["令和",null,"〇",null,"年",null,"〇",null,"月",null,"〇",null,"日"]
["（フリガナ）",null,null,null,null,null,null,null,null,null,null,"ホッカイ　タロウ"]
["　受領委任の施術管理者氏名",null,null,null,null,null,null,null,null,null,null,"北海　太郎",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"大・昭・平・令",null,null,null,null,null,null,"〇",null,"年",null,"〇",null,"月",null,"〇",null,"日",null,"生",null,null,"性別：男・女"]
["　住所",null,null,"〒","000-0000",null,null,null,null,null,null,"北海道○○市○○町1-2-3",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"TEL：",null,null,"000",null,null,null,"－","000",null,null,null,"－","0000"]
["（フリガナ）",null,null,null,null,null,null,null,null,null,null,"カブシキガイシャ　ホッカイコウセイ　ダイヒョウトリシマリヤウ　ホッカイ　ハナコ"]
["　開設者氏名",null,null,null,null,null,"株式会社　北海厚生　代表取締役　北海　花子",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"大・昭・平・令",null,null,null,null,null,null,"〇",null,"年",null,"〇",null,"月",null,"〇",null,"日",null,"生",null,null,"性別：男・女"]
["　住所",null,null,"〒","987-6543",null,null,null,null,null,null,"北海道○○市○○町7-8-9",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"TEL：",null,null,"000",null,null,null,"－","123",null,null,null,"－","9876"]
[]
[]
[]
["注　開設者氏名は、開設者と施術管理者が同一人の場合は「同上」と記入すること。"]
["（この申し出は、地方厚生（支）局（地方厚生（支）局が所在しない都府県にあっては地方厚生（支）局都道府県事務所）へ提出してください。）"]

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[]
[]
["（様式第４号）"]
["柔道整復施術療養費の受領委任の取扱いに係る申出事項の変更等"]
[]
["柔道整復師\n（受領委任の\n施術管理者）",null,null,null,null,null,"登録記号番号",null,null,null,null,null,"契0000000-0-0"]
[null,null,null,null,null,null,"氏名",null,null,null,null,null,"北海　太郎"]
[]
[null,null,null,null,null,null,"施術所名",null,null,null,null,null,"北海道接骨院"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（電話番号：",null,null,null,null,"000-000-0000",null,null,null,null,null,null,null,null,null,null,"）"]
[null,null,null,null,null,null,"開設者氏名",null,null,null,null,null,"氏名",null,"株式会社　北海厚生　代表取締役　北海　花子"]
["区分",null,"１　柔道整復師の施術に係る療養費の算定基準の備考５に基づく施術所の届出",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"定額料金の徴収を（　行う・中止　）"]
[]
[null,null,"２その他",null,"変更内容",null,"〇〇の変更（例：勤務者の追加（北海　三郎）、施術所名称変更（〇〇〇→△△△）等）"]
[]
[]
[]
[null,null,null,null,null,null,"（変更年月日：",null,null,null,null,null,"令和",null,"〇",null,"年",null,"〇",null,"月",null,"〇",null,"日",null,"）"]
[null,null,null,null,"理由等",null,"〇〇のため（例：新たに雇用したため、施術所名称変更のため　等）"]
[]
[]
[]
[]
["上記のとおり申出事項の変更を申し出します。"]
[null,"令和",null,"〇",null,"年","〇",null,"月","〇",null,"日"]
[]
[null,null,"北海道厚生局長"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"殿",null,null,null,null,"柔道整復師名",null,null,null,null,null,null,"北海　太郎"]
[null,null,"北海道知事"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"住所",null,null,null,null,null,null,"北海道○○市○○町1-2-3"]
[]
["（この申し出は、北海道厚生局へ提出してください。）"]
["（注）当該柔道整復師（受領委任の施術管理者）が死亡した場合は、事実が確認できる書類として住民票等の書類を添付"]
["　　し、申出人の氏名及び住所並びに当該柔道整復師との関係を記入すること。"]
["　　　また、施術所において勤務する他の柔道整復師を追加する場合は、様式第２号の２等を添付すること。"]

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[]
[]
["施術管理者選任証明"]
[]
[]
[]
[]
["施術所の「施術管理者」として、下記の柔道整復師を選任したことを証明する。"]
[]
[]
["記"]
[]
[]
[null,null,"施術所名称",null,null,null,null,null,null,null,null,"北海道接骨院"]
[]
[]
[]
[]
[null,null,"施術所住所",null,null,null,null,null,null,null,null,"〒","123-4567"]
[null,null,null,null,null,null,null,null,null,null,null,"北海道○○市○○町1-1-1"]
[]
[]
[]
[null,null,"施術管理者氏名",null,null,null,null,null,null,null,null,"北海　太郎"]
[]
[]
[]
[]
[null,null,"施術管理者住所",null,null,null,null,null,null,null,null,"〒","000-0000"]
[null,null,null,null,null,null,null,null,null,null,null,"北海道○○市○○町1-2-3"]
[]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"令和",null,"〇",null,"年",null,"〇",null,"月",null,"〇",null,"日"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"〒","987-6543"]
[null,null,null,null,null,null,null,null,null,null,null,"開設者住所",null,null,null,null,null,"北海道○○市○○町7-8-9"]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,"開設者氏名",null,null,null,null,null,"株式会社　北海厚生"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"代表取締役　北海　花子"]
[]
[]
["　　　　　[記載上の注意]　　開設者と施術管理者が異なる場合に提出してください。"]

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[]
[]
[]
[null,"勤　務　形　態　確　認　票"]
[]
[null,"柔道整復師名","北海　太郎",null,null,null,null,null,null,null,null,null,"自宅住所",null,null,"北海道○○市○○町1-2-3"]
[null,"施術所名称","厚生接骨院",null,null,null,null,null,null,null,null,null,"北海道接骨院"]
[null,"施術所所在地","北海道○○市△△町9-8-7",null,null,null,null,null,null,null,null,null,"北海道○○市○○町1-1-1"]
[null,"管理・勤務の区分","管 理　・　勤 務",null,null,null,null,null,null,null,null,null,"管 理　・　勤 務",null,null,null,null,null,null,null,null,null,"管 理　・　勤 務"]
[null,"勤 務 時 間","曜日（火木）",null,null,null,null,null,null,null,null,null,"曜日（月水金）",null,null,null,null,null,null,null,null,null,"曜日（　　　　　　　　　）"]
[null,null,"ＡＭ",null,"10","：","00","～","12","：","00",null,"ＡＭ",null,"10","：","00","～","12","：","00",null,"ＡＭ",null,null,"：",null,"～",null,"："]
[null,null,"ＰＭ",null,null,"：",null,"～",null,"：",null,null,"ＰＭ",null,"13","：","00","～","17","：","00",null,"ＰＭ",null,null,"：",null,"～",null,"："]
[null,null,"曜日（　　　　　　　　　）",null,null,null,null,null,null,null,null,null,"曜日（火木）",null,null,null,null,null,null,null,null,null,"曜日（　　　　　　　　　）"]
[null,null,"ＡＭ",null,null,"：",null,"～",null,"：",null,null,"ＡＭ",null,null,"：",null,"～",null,"：",null,null,"ＡＭ",null,null,"：",null,"～",null,"："]
[null,null,"ＰＭ",null,null,"：",null,"～",null,"：",null,null,"ＰＭ",null,"13","：","00","～","18","：","00",null,"ＰＭ",null,null,"：",null,"～",null,"："]
[null,null,"曜日（　　　　　　　　　）",null,null,null,null,null,null,null,null,null,"曜日（　　　　　　　　　）",null,null,null,null,null,null,null,null,null,"曜日（　　　　　　　　　）"]
[null,null,"ＡＭ",null,null,"：",null,"～",null,"：",null,null,"ＡＭ",null,null,"：",null,"～",null,"：",null,null,"ＡＭ",null,null,"：",null,"～",null,"："]
[null,null,"ＰＭ",null,null,"：",null,"～",null,"：",null,null,"ＰＭ",null,null,"：",null,"～",null,"：",null,null,"ＰＭ",null,null,"：",null,"～",null,"："]
[null,"休　業　日","日 ・ 月 ・ 火 ・ 水 ・ 木 ・ 金 ・ 土",null,null,null,null,null,null,null,null,null,"日 ・ 月 ・ 火 ・ 水 ・ 木 ・ 金 ・ 土",null,null,null,null,null,null,null,null,null,"日 ・ 月 ・ 火 ・ 水 ・ 木 ・ 金 ・ 土"]
[null,null,"祝祭日　・　振替休日",null,null,null,null,null,null,null,null,null,"祝祭日　・　振替休日",null,null,null,null,null,null,null,null,null,"祝祭日　・　振替休日"]
[null,null,"その他（",null,null,null,null,null,null,null,null,"）","その他（",null,null,null,null,null,null,null,null,"）","その他（",null,null,null,null,null,null,null,null,"）"]
[null,"　同一日に複数の施術所に勤務する必要がある場合の移動手段","①","当初勤務する施術所の住所",null,null,null,null,null,null,null,null,"北海道○○市△△町9-8-7"]
[null,null,null,"移 動 先 施 術 所 の 住 所",null,null,null,null,null,null,null,null,"北海道○○市○○町1-1-1"]
[null,null,null,"施　術　所　間　の　距　離",null,null,null,null,null,null,null,null,"（",null,5,null,null,null,null,"）Ｋｍ"]
[null,null,null,"移　　　 動　　　 手　　　 段",null,null,null,null,null,null,null,null,"区　　　　　間",null,null,null,null,null,null,null,null,null,"距　　離　　・　　時　　間"]
[null,null,null,"電車・バス・車・徒歩・その他（",null,null,null,null,null,null,null,"）","（","厚生接骨院",null,"）から（",null,"北海道接骨院",null,null,null,"）","（",5,"）Km",null,"（",15,null,"）分"]
[null,null,null,"電車・バス・車・徒歩・その他（",null,null,null,null,null,null,null,"）","（",null,null,"）から（",null,null,null,null,null,"）","（",null,"）Km",null,"（",null,null,"）分"]
[null,null,null,"電車・バス・車・徒歩・その他（",null,null,null,null,null,null,null,"）","（",null,null,"）から（",null,null,null,null,null,"）","（",null,"）Km",null,"（",null,null,"）分"]
[null,null,"②","当初勤務する施術所の住所"]
[null,null,null,"移 動 先 施 術 所 の 住 所"]
[null,null,null,"施　術　所　間　の　距　離",null,null,null,null,null,null,null,null,"（",null,null,null,null,null,null,"）Ｋｍ"]
[null,null,null,"移　　　 動　　　 手　　　 段",null,null,null,null,null,null,null,null,"区　　　　　間",null,null,null,null,null,null,null,null,null,"距　　離　　・　　時　　間"]
[null,null,null,"電車・バス・車・徒歩・その他（",null,null,null,null,null,null,null,"）","（",null,null,"）から（",null,null,null,null,null,"）","（",null,"）Km",null,"（",null,null,"）分"]
[null,null,null,"電車・バス・車・徒歩・その他（",null,null,null,null,null,null,null,"）","（",null,null,"）から（",null,null,null,null,null,"）","（",null,"）Km",null,"（",null,null,"）分"]
[null,null,null,"電車・バス・車・徒歩・その他（",null,null,null,null,null,null,null,"）","（",null,null,"）から（",null,null,null,null,null,"）","（",null,"）Km",null,"（",null,null,"）分"]
[null,null,"③","当初勤務する施術所の住所"]
[null,null,null,"移 動 先 施 術 所 の 住 所"]
[null,null,null,"施　術　所　間　の　距　離",null,null,null,null,null,null,null,null,"（",null,null,null,null,null,null,"）Ｋｍ"]
[null,null,null,"移　　　 動　　　 手　　　 段",null,null,null,null,null,null,null,null,"区　　　　　間",null,null,null,null,null,null,null,null,null,"距　　離　　・　　時　　間"]
[null,null,null,"電車・バス・車・徒歩・その他（",null,null,null,null,null,null,null,"）","（",null,null,"）から（",null,null,null,null,null,"）","（",null,"）Km",null,"（",null,null,"）分"]
[null,null,null,"電車・バス・車・徒歩・その他（",null,null,null,null,null,null,null,"）","（",null,null,"）から（",null,null,null,null,null,"）","（",null,"）Km",null,"（",null,null,"）分"]
[null,null,null,"電車・バス・車・徒歩・その他（",null,null,null,null,null,null,null,"）","（",null,null,"）から（",null,null,null,null,null,"）","（",null,"）Km",null,"（",null,null,"）分"]
[null,"備　　考"]
[]
[null,"※　同一日に複数の施術所に勤務する場合は、それぞれの施術所間の移動手段、移動時間等を記載してください。"]

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[]
[]
["別紙様式１"]
[]
[]
[]
[null,"実 務 経 験 期 間 証 明 書"]
[]
[null,"次の者は当施設において、柔道整復師として実務に従事したことを証明します。"]
[]
[null,"氏　　名",null,"　北海　太郎"]
[null,"生年月日",null,null,"○",null,"○",null,"○"]
[null,null,null,"昭　和"]
[null,null,null,"・",null,"年",null,"月",null,"日"]
[null,null,null,"平　成"]
[]
[null,"従事期間",null,"昭　和",28,null,4,null,1,null,null,"昭　和",3,null,5,null,31]
[null,null,null,"・",null,null,null,null,null,null,null,"・"]
[null,null,null,"平　成",null,"年",null,"月",null,"日","～","平　成",null,"年",null,"月",null,"日"]
[null,null,null,"・",null,null,null,null,null,null,null,"・"]
[null,null,null,"令　和",null,null,null,null,null,null,null,"令　和"]
[null,null,null,5,"年",2,"ヵ月"]
[]
[null,"令和","○","年","○","月","○","日"]
[]
[null,null,null,null,null,null,null,null,"施　設　名"]
[null,null,null,null,null,null,null,null,null,"厚労接骨院"]
[]
[null,null,null,null,null,null,null,null,"登録記号番号（又は医療機関コード）"]
[null,null,null,null,null,null,null,null,null,"契０００００００－０－０"]
[]
[null,null,null,null,null,null,null,null,"所　在　地"]
[null,null,null,null,null,null,null,null,null,"北海道○○市○○町3-4-5"]
[]
[null,null,null,null,null,null,null,null,"ＴＥＬ",null,null,"456-789-1234"]
[]
[null,null,null,null,null,null,null,null,"管理者職名",null,null,"施術管理者"]
[null,null,null,null,null,null,null,null,"及び氏名",null,null,"厚労　一郎"]
[]
[null,"（注）","１．柔道整復師としての実務経験期間を記載すること。"]
[null,null,"２．虚偽の証明を行ったときは、受領委任の取扱いの中止又は中止相当となります。"]