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["別記第１号様式（第５条関係）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,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,null,null,null,null,"年",null,null,null,"月",null,null,null,"日",null,null,null,null,null,null,"⇒記入日を記入"]
[]
["介護予防訪問介護サービス 時間延長等 事業利用 申 請 書 兼 派遣指示書"]
["渋谷区長　殿",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（　　事業対象者　　　　要支援 1 　　　要支援 2）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,false,false,false,null,null,"⇒該当の認定区分に☑をいれる。"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"フリガナ"]
["訪問介護事業者　",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,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,null,null,null,null,null,null,null,null,"⇒申請者についての情報を記入"]
[null,"サービス提供事業者名",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,"被保険者番号"]
[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,"住　　　所　　",null,null,null,null,null,null,"渋谷区",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(BG10=TRUE,AN10+1867,)","v":0},{"$f":"IF(BH10=TRUE,AN10+1911,)","v":0},{"$f":"IF(BI10=TRUE,AN10+1925,0)","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"電話番号",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(BG10=TRUE,BG8,IF(BH10=TRUE,BH8,BI8))","v":0}]
[null,null,null,null,null,null,null,null,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,"　","明",null,"大",null,"昭",null,null,null,"年",null,null,null,"月",null,null,null,"日",null,"年齢（",null,null,{"$f":"IF(AV10=\"\",\"\",DATEDIF(BG9&\"年\"&AR10&\"月\"&AV10&\"日\",TODAY(),\"Y\"))","v":""},null,"歳）",null,false,false,false,null,null,"⇒年号に☑をいれ、生年月日を入力すると年齢は自動で計算"]
[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,"同居家族の有無",null,null,null,null,null,null,null,null,null,null,null,null,"有",null,null,null,null,null,null,"無",null,null,null,null,null,null,null,null,null,null,false,false]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"生活保護受給の有無",null,null,null,null,null,null,null,null,null,null,null,null,"有",null,null,null,null,null,null,"無",null,null,null,null,null,null,null,null,null,null,false,false]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"⇒押印は不要となりました。"]
[]
["地域包括支援センター・ケアマネジャー記入欄"]
["派遣開始日",null,null,null,null,"令和",null,null,null,null,null,null,"年",null,null,null,null,"月",null,null,null,null,null,"日"]
["派遣希望回数及び時間数　（御利用時間は午前８時から午後７時までです。）"]
["　　　時 間 延 長　　",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,false]
["① サービス内　容No.",null,null,null,"総合事業の利用回数 （※）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"派 遣 希 望 回 数　",null,null,null,null,null,null,null,null,null,null,null,"派 遣 希 望 時 間 数"]
[null,null,null,null,"国基準訪問サービス　　週",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"回",null,"利用",null,null,null,null,"週",null,null,null,null,null,"回",null,null,null,"　３０分　・　　　１時間　",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,false,false]
[null,null,null,null,"国基準訪問サービス　　週",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"回",null,"利用",null,null,null,null,"週",null,null,null,null,null,"回",null,null,null,"　３０分　・　　　１時間　"]
[null,null,null,null,"国基準訪問サービス　　週",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"回",null,"利用",null,null,null,null,"週",null,null,null,null,null,"回",null,null,null,"　３０分　・　　　１時間　"]
["　　　回 数 追 加",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,false]
["① サービス内　容No.",null,null,null,"総合事業の利用回数 （※）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"派 遣 希 望 時 間 数"]
[null,null,null,null,"国基準訪問サービス　　週",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"回",null,"利用",null,null,null,null," ３０分",null,null,null,"１時間",null,null,null,"１時間３０分",null,null,null,null,null,null,null,"２時間　　",null,null,null,null,null,null,"２時間３０分",null,null,null,null,null,null,false,false,false,false,false]
["※　派遣開始日時点の総合事業の利用回数をご記入ください。"]
["該当する□全てにレ印をつけてください。"]
["① サービス内容"]
[null,null,null,null,"１　食事の準備、調理",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"２　洗濯、衣類の整理、補修",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"３　居室等の掃除"]
[null,null,null,null,"４　身体介護［",null,null,null,null,null,null,null,null,null,null,"食事介助",null,null,null,null,null,null,null,"入浴介助",null,null,null,null,null,null,"身体整容",null,null,null,null,null,"通院・外出介助",null,null,null,null,null,null,null,null,null,null,"服薬介助"]
[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,false]
["② サービスが必要な理由　（利用者の状態、期待される効果等）"]
[]
[]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"地域包括支援センター",null,null,null,null,null,null,null,null,null,null,null,"担　当："]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"居宅介護支援事業所",null,null,null,null,null,null,null,null,null,null,null,"連絡先："]

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["別記第１号様式（第５条関係）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,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,null,null,null,null,"年",null,null,null,"月",null,null,null,"日",null,null,null,null,"⇒記入日を記入"]
[]
["介護予防訪問介護サービス 時間延長等 事業利用 申 請 書 兼 派遣指示書"]
["渋谷区長　殿",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（　　事業対象者　　　　要支援 1 　　　要支援 2）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,false,false,false,"⇒該当の認定区分に☑をいれる。"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"フリガナ"]
["訪問介護事業者　",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,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,null,null,null,null,null,null,"⇒申請者についての情報を記入"]
[null,"サービス提供事業者名",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,"被保険者番号"]
[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,"住　　　所　　",null,null,null,null,null,null,"渋谷区",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(BG10=TRUE,AN10+1867,)","v":0},{"$f":"IF(BH10=TRUE,AN10+1911,)","v":0},{"$f":"IF(BI10=TRUE,AN10+1925,0)","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"電話番号",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(BG10=TRUE,BG8,IF(BH10=TRUE,BH8,BI8))","v":0}]
[null,null,null,null,null,null,null,null,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,"　","明",null,"大",null,"昭",null,null,null,"年",null,null,null,"月",null,null,null,"日",null,"年齢（",null,null,{"$f":"IF(AV10=\"\",\"\",DATEDIF(BG9&\"年\"&AR10&\"月\"&AV10&\"日\",TODAY(),\"Y\"))","v":""},null,"歳）",null,false,false,false,"⇒年号に☑をいれ、生年月日を入力すると年齢は自動で計算"]
[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,"同居家族の有無",null,null,null,null,null,null,null,null,null,null,null,null,"有",null,null,null,null,null,null,"無",null,null,null,null,null,null,null,null,null,null,false,false]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"生活保護受給の有無",null,null,null,null,null,null,null,null,null,null,null,null,"有",null,null,null,null,null,null,"無",null,null,null,null,null,null,null,null,null,null,false,false]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"⇒押印は不要となりました。"]
[]
["地域包括支援センター・ケアマネジャー記入欄"]
["派遣開始日",null,null,null,null,"令和",null,null,null,null,null,null,"年",null,null,null,null,"月",null,null,null,null,null,"日"]
["派遣希望回数及び時間数　（御利用時間は午前８時から午後７時までです。）"]
["　　　時 間 延 長　　"]
["① サービス内　容No.",null,null,null,"総合事業の利用回数 （※）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"派 遣 希 望 回 数　",null,null,null,null,null,null,null,null,null,null,null,"派 遣 希 望 時 間 数"]
[null,null,null,null,"国基準訪問サービス　　週",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"回",null,"利用",null,null,null,null,"週",null,null,null,null,null,"回",null,null,null,"　３０分　・　　　１時間　"]
[null,null,null,null,"国基準訪問サービス　　週",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"回",null,"利用",null,null,null,null,"週",null,null,null,null,null,"回",null,null,null,"　３０分　・　　　１時間　"]
[null,null,null,null,"国基準訪問サービス　　週",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"回",null,"利用",null,null,null,null,"週",null,null,null,null,null,"回",null,null,null,"　３０分　・　　　１時間　"]
["　　　回 数 追 加"]
["① サービス内　容No.",null,null,null,"総合事業の利用回数 （※）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"派 遣 希 望 時 間 数"]
[null,null,null,null,"国基準訪問サービス　　週",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"回",null,"利用",null,null,null,null," ３０分",null,null,null,"１時間",null,null,null,"１時間３０分",null,null,null,null,null,null,null,"２時間　　",null,null,null,null,null,null,"２時間３０分"]
["※　派遣開始日時点の総合事業の利用回数をご記入ください。"]
["該当する□全てにレ印をつけてください。"]
["① サービス内容"]
[null,null,null,null,"１　食事の準備、調理",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"２　洗濯、衣類の整理、補修",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"３　居室等の掃除"]
[null,null,null,null,"４　身体介護［",null,null,null,null,null,null,null,null,null,null,"食事介助",null,null,null,null,null,null,null,"入浴介助",null,null,null,null,null,null,"身体整容",null,null,null,null,null,"通院・外出介助",null,null,null,null,null,null,null,null,null,null,"服薬介助"]
[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,false]
["② サービスが必要な理由　（利用者の状態、期待される効果等）"]
[]
[]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"地域包括支援センター",null,null,null,null,null,null,null,null,null,null,null,"担　当："]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"居宅介護支援事業所",null,null,null,null,null,null,null,null,null,null,null,"連絡先："]

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["別記第１号様式（第５条関係）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,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,8,null,null,null,"年",null,3,null,"月",null,1,null,"日",null,null,null,null,"⇒記入日を記入"]
[]
["介護予防訪問介護サービス 時間延長等 事業利用 申 請 書 兼 派遣指示書"]
["渋谷区長　殿",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（　　事業対象者　　　　要支援 1 　　　要支援 2）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,false,false,true,"⇒該当の認定区分に☑をいれる。"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"フリガナ",null,null,null,null,null,null,null,null,"シブヤ　タロウ"]
["訪問介護事業者　",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"氏名",null,null,null,null,null,null,null,null,"渋谷　太郎",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"⇒申請者についての情報を記入"]
[null,"サービス提供事業者名",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,"被保険者番号",null,null,null,null,null,null,null,null,"123456"]
[null,"ホームヘルプ△△\n渋谷□□サービス",null,null,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,"渋谷区",null,null,null,"宇田川町１－１",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(BG10=TRUE,AN10+1867,)","v":0},{"$f":"IF(BH10=TRUE,AN10+1911,)","v":0},{"$f":"IF(BI10=TRUE,AN10+1925,0)","v":1932}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"電話番号",null,null,null,null,null,null,"03-3463-1211",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(BG10=TRUE,BG8,IF(BH10=TRUE,BH8,BI8))","v":1932}]
[null,null,null,null,null,null,null,null,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,"　","明",null,"大",null,"昭",null,7,null,"年",null,10,null,"月",null,1,null,"日",null,"年齢（",null,null,{"$f":"IF(AV10=\"\",\"\",DATEDIF(BG9&\"年\"&AR10&\"月\"&AV10&\"日\",TODAY(),\"Y\"))","v":93},null,"歳）",null,false,false,true,"⇒年号に☑をいれ、生年月日を入力すると年齢は自動で計算"]
[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,"同居家族の有無",null,null,null,null,null,null,null,null,null,null,null,null,"有",null,null,null,null,null,null,"無",null,null,null,null,null,null,null,null,null,null,false,true]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"生活保護受給の有無",null,null,null,null,null,null,null,null,null,null,null,null,"有",null,null,null,null,null,null,"無",null,null,null,null,null,null,null,null,null,null,true,false]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"⇒押印は不要となりました。"]
[]
["地域包括支援センター・ケアマネジャー記入欄"]
["派遣開始日",null,null,null,null,"令和",null,null,null,8,null,null,"年",null,3,null,null,"月",null,null,14,null,null,"日"]
["派遣希望回数及び時間数　（御利用時間は午前８時から午後７時までです。）"]
["　　　時 間 延 長　　"]
["① サービス内　容No.",null,null,null,"総合事業の利用回数 （※）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"派 遣 希 望 回 数　",null,null,null,null,null,null,null,null,null,null,null,"派 遣 希 望 時 間 数"]
[4,null,null,null,"国基準訪問サービス　　週",null,null,null,null,null,null,null,null,null,null,null,null,null,1,null,null,"回",null,"利用",null,null,null,null,"週",null,null,1,null,null,"回",null,null,null,"　３０分　・　　　１時間　"]
[null,null,null,null,"国基準訪問サービス　　週",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"回",null,"利用",null,null,null,null,"週",null,null,null,null,null,"回",null,null,null,"　３０分　・　　　１時間　"]
[null,null,null,null,"国基準訪問サービス　　週",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"回",null,"利用",null,null,null,null,"週",null,null,null,null,null,"回",null,null,null,"　３０分　・　　　１時間　"]
["　　　回 数 追 加"]
["① サービス内　容No.",null,null,null,"総合事業の利用回数 （※）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"派 遣 希 望 時 間 数"]
[null,null,null,null,"国基準訪問サービス　　週",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"回",null,"利用",null,null,null,null," ３０分",null,null,null,"１時間",null,null,null,"１時間３０分",null,null,null,null,null,null,null,"２時間　　",null,null,null,null,null,null,"２時間３０分"]
["※　派遣開始日時点の総合事業の利用回数をご記入ください。"]
["該当する□全てにレ印をつけてください。"]
["① サービス内容"]
[null,null,null,null,"１　食事の準備、調理",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"２　洗濯、衣類の整理、補修",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"３　居室等の掃除"]
[null,null,null,null,"４　身体介護［",null,null,null,null,null,null,null,null,null,null,"食事介助",null,null,null,null,null,null,null,"入浴介助",null,null,null,null,null,null,"身体整容",null,null,null,null,null,"通院・外出介助",null,null,null,null,null,null,null,null,null,null,"服薬介助"]
[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,false]
["② サービスが必要な理由　（利用者の状態、期待される効果等）"]
[]
[]
[]
[]
[]
[]
[null,"○○ケアプランサービス",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"地域包括支援センター",null,null,null,null,null,null,null,null,null,null,null,"担　当：",null,null,null,null,"福祉　八公"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"居宅介護支援事業所",null,null,null,null,null,null,null,null,null,null,null,"連絡先：",null,null,null,null,"03-3463-xxxx"]