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[null,null,null,null,"四 輪 自 動 車 試 験 依 頼 書",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"受付番号","受付日",null,null,null,null,null,null,null,"年",null,null,"月",null,null,"日"]
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[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"排出ガス",null,null,null,"№"]
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[null,"一般財団法人　日本車両検査協会　　殿",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"加速騒音",null,null,null,"№"]
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[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※上記枠内は記入しないで下さい。"]
[]
[null,null,"別紙の自動車排出ｶﾞｽ試験及び加速走行騒音試験等のご案内を了承のうえ下記の試験を依頼します。"]
[]
[null,"※","この依頼書は依頼事項 1件 につき １部 になります。\n排出ガス試験と加速騒音試験を同時に依頼される場合、依頼書は 2部 ご提出下さい。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,null,"月",null,null,"日"]
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[null,"試験依頼者",null,null,null,"〒",null,null,null,"-",null,null,null,"TEL",null,null,null,null,null,null,null,null,null,null,null,null,"FAX"]
[null,"住　　所"]
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[null,"氏　　名"]
[null,"又は名称",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※必ず押印下さい。"]
[]
[null,"車　　　　　　名",null,null,null,null,null,null,null,null,null,null,null,null,"型式 又は 車両種別",null,null,null,null,null,null,null,null,null,null,null,"車台番号（シリアル番号）"]
[]
[]
[null,"輸入者名（並行輸入車試験時）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"改造内容（改造車試験時）"]
[]
[]
[null,"排出ガス試験区分",null,null,null,null,null,null,null,null,null,"排出ガス規制年度",null,null,null,null,null,null,null,null,"試験項目（モード）",null,null,null,null,null,null,null,null,null,"粒子状物質(PM/PN)測定"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年規制"]
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[null,"製造年月日 又は 年式",null,null,null,null,null,null,null,null,"用途",null,null,null,null,"駆動輪",null,null,null,null,"燃料の種類",null,null,null,null,"変速機",null,null,null,null,"車両重量"]
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[]
[null,"加速走行騒音試験区分",null,null,null,null,null,null,null,null,"騒音防止性能確認標章の有無",null,null,null,null,null,null,null,null,null,"整備・対策の完了日",null,null,null,null,null,null,null,null,null,"試験場所"]
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[null,null,null,null,null,null,null,null,null,null,null,null,null,"（有料 1,100円）",null,null,null,null,null,null,"以降受験可能"]
[null,"試験日通知等の試験担当連絡者氏名、電話番号、FAX番号",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"試験料金銀行振込名義（試験依頼者、輸入者以外の場合）"]
[null,"氏名"]
[]
[null,"TEL",null,null,null,null,null,null,null,null,null,"FAX"]
[null,"試験成績書受領方法",null,null,null,null,null,null,null,null,null,null,null,null,null,"宅急便による送り先（上記依頼者以外の場合）"]
[null,null,null,"手渡し",null,null,null,null,null,null,"宅急便（着払い）",null,null,null,null,"〒",null,null,null,"-",null,null,null,null,null,null,null,null,"TEL"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"住所"]
[null,"※ 記入の無い場合は、依頼者宛に着払い宅急便にて発送いたします。",null,null,null,null,null,null,null,null,null,null,null,null,null,"氏名又は名称"]
[null,"1.","受付時に他の申請必要書類と共にご提出下さい。\nこの依頼書受付後のｺﾋﾟｰが控え及び受験票となります。"]
[null,"2.","並行輸入車は諸元表、通関証明書原本（確認後返却）、その他は諸元表、車検証、抹消証、完成検査証等のコピーが必要です。"]
[null,"3.","令和5年4月１日以降のガソリン直噴車（ストイキ）についてはＰＭ規制が適用されます。"]
[null,"4.","試験項目(モード) 及び 粒子状物質(PM/PN)測定等は、事前に自動車技術総合機構の各事務所に確認のうえご依頼下さい。"]
[null,"備　考","　※試験区分にて、改造・その他を選択された方は具体的な内容をご記入ください。\n　　 又、成績書表紙の宛名が依頼者と異なる場合にもご記入をお願いします。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"手数料（円）"]
[]
[]
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[]
[]
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[null,"- - - - - - - - - - - - - - - - - - - - - 協　会　記　入　欄　（下記枠内には記入しないで下さい） - - - - - - - - - - - - - - - - - - - - -"]
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[null,null,null,null,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,"区\n分"]