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["１級鑑定人登録申請書"]
[null,"一般社団法人　日本損害保険協会　御中"]
[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,null,"適格請求書（領収証）※要記載"]
[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,null,"必要",null,null,null,null,null,null,null,null,null,null,"不要"]
[null,"提出写真について（厳守）\n １．申請前６か月以内に撮影したもの（モノクロも可）\n ２．無帽、正面、上三分身、無背景のたて30ミリ・よこ24ミリのものを１枚\n ３．写真裏面に登録番号、氏名をはっきり記入すること\n ４．写真は透明のビニール袋に入れ、ホチキス等で申請用紙に止めること",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,"宛名",null,null,null,null,"　　申請者氏名"]
[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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　　勤務先"]
[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,null,null,null,null,null,null,"　　その他"]
[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,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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"申請日（西暦）",null,null,null,null,null,null,null,null,"：",null,null,null,null,null,"年",null,null,null,null,"月",null,null,null,null,"日"]
[null,"ふりがな"]
[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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"印"]
[null,"現 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,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,"FAX番号",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,"E-mail:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"＠"]
[null,"生年月日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"(西暦)",null,null,null,null,null,null,null,null,null,null,null,"年",null,null,null,null,null,"月",null,null,null,null,null,"日",null,null,"満",null,null,null,null,null,"歳"]
[null,"勤務先",null,null,null,null,null,null,null,null,null,"商号・名称\n（注１）"]
[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,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,"FAX番号",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,"E-mail:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"＠"]
[null,"２級鑑定人登録日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"(西暦)",null,null,null,null,null,null,null,null,null,null,null,"年",null,null,null,null,null,"月",null,null,null,null,null,"日"]
[null,"現在の登録番号",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,null,null,"－",null,null,null,null,null,null,null,null,null,null,null,"不明"]
[null,"取 得 済 単 位",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　 保       険・一 般 常 識",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"建  　   築"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　 電  　   気",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"機  　   械"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　 簿 記 会 計　",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"研 究 レ ポ ー ト"]
[null,"専 門 鑑 定 人 Ａ・Ｂ\n同 時 登 録　(注２）　　　",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"  取 得 公 的 資 格 名"]
[]
[null,"有　　　無"]
[null,"保険会社へのデータ開示\n（注３）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"勤務先",null,null,null,null,null,null,null,null,null,null,null,"自宅",null,null,null,null,null,null,null,null,null,null,null,null,"開示しない"]
[null,"登録証・案内などの送付先",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"勤務先",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"自宅"]
[null,"反社会的勢力\nとの関係",null,null,null,null,null,null,null,null,"鑑定人規則では、受験申請時、登録申請時および登録において、いわゆる｢反社会的勢力」であること、または関係すること等を禁じていますので、申請者が以下の各項目に当てはまらないことを確認いたします。内容を確認のうえ下記ボックスに☑印をつけてください。１つでも当てはまる場合は登録申請はできません。"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"登録申請者である私は、以下の各項目のすべてに当てはまりません。"]
[null,null,null,null,null,null,null,null,null,null,"・暴力団員（暴力団員ではなくなった日から５年を経過しない者を含む。）、暴力団準構成員、暴力団関係企業その他の\n　反社会的勢力（以下「反社会的勢力」という。）に該当する。\n・反社会的勢力に対して資金等を提供し、または便宜を供与するなどの関与をしている。\n・反社会的勢力を不当に利用している。\n・反社会的勢力と社会的に非難されるべき関係を有している。\n・自らまたは第三者を利用して、暴力、脅迫、威力または詐欺的言動その他違法ないし不当な言動を行っている。"]
[]
[]
[null,"（注１）",null,null,null,"支店名、支社名、部署名等も記入してください。"]
[null,"（注２）",null,null,null,"公的資格を証明する書類（写）を添付してください。"]
[null,"（注３）",null,null,null,"一般社団法人 日本損害保険協会は、登録申請にあたり、申請者本人から取得する現住所、氏名、生年月日、電話番号、勤務先などの情報、登録のために必要な範囲でこれを利用し、それ以外の目的でこれらの情報を利用することはありません。また、取得した情報は、登録申請者データとしてその保守・管理を厳格に行うとともに、安全面に関する必要かつ的確な措置を講じています。なお、貴殿が、保険会社に対し、データ開示を同意されない場合には、上記データ開示欄の「しない」のボックスに☑印をつけてください。"]
[null,"登録料および振込口座は次のとおりです。複数名分を一括して振込む場合は、下記「一括振込欄」のボックスに☑印をつけてください。"]
[null,"振 込 口 座",null,null,null,null,null,null,null,null,"◎登録料（2,200円（税込））\n三菱ＵＦＪ銀行　日本橋中央支店　当座預金　０３３３０１１\n口座名義：一般社団法人　日本損害保険協会",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,null,"一括振込"]