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[null,"健診の流れ"]
[]
[null,null,null,"共済組合"]
[null,null,null,"「平成２４年度　任意継続組合員の皆様へのご案内」を送付"]
[]
[]
[null,null,"人間ドックを希望",{"$nulls":6},"人間ドックを希望しない"]
[null,null,"人間ドック申込書を４月２０日(金)までに共済組合へ送付（ＦＡＸ可）"]
[null,null,null,"共済組合"]
[null,null,null,"５月中に「人間ドック受検者証」又は「特定健康診査受診券」及び検査・健診機関等の資料を自宅へ送付"]
[]
[null,"任意継続組合員・被扶養者",null,null,null,"受検する"]
[]
[null,null,"人間ドック検査",{"$nulls":4},"特定健康診査"]
[{"$nulls":5},"又は"]
[]
[]
[]
[null,null,"歯 科 健 診 申 込 書"]
[{"$nulls":9},"令和　　年　　月　　日"]
[]
["組合員情報",null,"組 合 員 証　記 号 番 号","-"]
[null,null,"組合員氏名"]
[]
[]
[null,null,"歯科健診希望者（組合員・被扶養者）"]
["受診希望者",null," 氏　　名",{"$nulls":6},"組合員\nとの続柄"]
[null,null,"生 年 月 日",null,"　昭和\n　平成\n　令和","　　　年　　　月　　　日"]
["受診希望者",null," 氏　　名",{"$nulls":6},"組合員\nとの続柄"]
[null,null,"生 年 月 日",null,"　昭和\n　平成\n　令和","　　　年　　　月　　　日"]
["受診希望者",null," 氏　　名",{"$nulls":6},"組合員\nとの続柄"]
[null,null,"生 年 月 日",null,"　昭和\n　平成\n　令和","　　　年　　　月　　　日"]
["受診希望者",null," 氏　　名",{"$nulls":6},"組合員\nとの続柄"]
[null,null,"生 年 月 日",null,"　昭和\n　平成\n　令和","　　　年　　　月　　　日"]
["受診希望者",null," 氏　　名",{"$nulls":6},"組合員\nとの続柄"]
[null,null,"生 年 月 日",null,"　昭和\n　平成\n　令和","　　　年　　　月　　　日"]
[null,"※組合員との続柄の欄は、受診希望者が組合員の場合は、「本人」とご記入ください。"]
[]
[null,null," ・健診は７月１日から翌年１月３１日までに受診してください。（厳守）"]
[null,null," ・この申込書を共済事務担当課に提出する前に、歯科健診の予約をしてください。"]
[null,null," ・健診は組合員・被扶養者とも、年度ごとに１人１回を限度とします。"]
[null,null,"・資格喪失後（被扶養者の扶養取消しを含みます。）に健診を受けられた場合は、"]
[null,null,"全額自己負担となります。"]
[]
[null,null,"共済事務担当課に提出してください。"]