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["別紙"]
[]
["米子医療センター緩和ケア研修会受講申込書"]
[]
["      独立行政法人国立病院機構　"]
[null,"米子医療センター院長　様"]
[]
["「米子医療センター緩和ケア研修会募集要領」の受講を申し込みます。"]
[]
["記"]
[]
["　　１．受講希望者"]
[null,"（１）","氏　　名："]
[null,"（２）","よみがな："]
[null,"（３）","所　　属："]
[null,"（４）","役　　職："]
[null,"（５）","診 療 科："]
[null,"（６）","e-learning受講時\nのメールアドレス"]
[null,"（７）連絡先","住　　所："]
[null,"（８）","電　　話："]
[]
[null,"※本紙をもとに修了証等を作成しますので、ご記入の際はお間違いの無いようお願い"]
[null,"　します。また、必ずふりがなをお書き添えください。"]
[]
["　　２．添付書類　　・医師免許証の写し（医師のみ）"]
["　　　　　　　　　　・e-learning修了証書の写し"]
[]
["　　３．修了者公表の可否"]
[null,"いずれかを「○」で囲んでください。（医師のみ）"]
[]
[null,"（１）　同意する　　　　　（２）　同意しない"]
[]
[null,"※この研修を修了したものは厚生労働省に報告され、原則として氏名及び所属が公開"]
[null,"　されることになっております。これに対する可否をお尋ねするものです。"]
[]
[]
["　　注意事項"]
[null,"昼食は、各自でご準備ください。"]