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[]
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[{"$nulls":20},"希望受験地"]
[{"$nulls":5},"乗 船 履 歴 認 定 申 請 書"]
[]
[]
[{"$nulls":5},"試験についての乗船履歴について、船舶職員及び小型船舶操縦者法施行規則第２８条の規定により"]
["認定を受けたいので、海上自衛隊の使用する船舶による乗船履歴証明書を添えて申請します。"]
[]
[{"$nulls":14},"申　請　者","　階級等",null,null,"　所属配置"]
[{"$nulls":3},"令和   年　 月　  日"]
[{"$nulls":15},"　氏　名",{"$nulls":4},"生年月日"]
[]
[{"$nulls":15},"　現住所"]
[]
[{"$nulls":15},"　現有海技免状",{"$nulls":4},"　同左番号"]
[]
[]
[{"$nulls":4},"海上自衛隊の使用する船舶による乗船履歴証明書"]
[]
["船舶名",null,null,"総トン数",null,null,"船舶の区分",null,"推進機関の種類",null,null,"職名\n（配置名）",null,"乗船年月日",null,null,"下船年月日",null,null,"乗船期間",null,null,"階　級"]
[{"$nulls":6},"自衛艦","支援船","及び出力"]
[{"$nulls":13},"",null,null,"",null,null,""]
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[{"$nulls":13},"",null,null,"",null,null,""]
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[{"$nulls":13},"",null,null,"",null,null,""]
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[{"$nulls":13},"",null,null,"",null,null,""]
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[{"$nulls":13},"",null,null,"",null,null,""]
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[{"$nulls":13},"",null,null,"",null,null,""]
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[{"$nulls":13},"",null,null,"",null,null,""]
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[{"$nulls":13},"",null,null,"",null,null,""]
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[{"$nulls":6},"該当欄に○\n印をつける",{"$nulls":6},"期　間　の　合　計",{"$nulls":5},""]
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[null,"上記のとおり相違ないことを証明する。"]
[{"$nulls":11},"令和",null,"年",null,"月",null,"日"]