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{"sheet":"事業概要報告書2(販売）","index":0,"n_rows":34,"n_cols":9,"rows_kept":34,"cut":false,"hidden":false,"merged":[[21,1,25,3],[21,5,22,7],[21,8,22,8],[23,5,23,8],[25,4,25,6],[20,5,20,8],[1,1,1,8],[0,7,0,8],[14,1,14,4],[14,5,14,8],[5,1,5,8],[6,5,6,6],[3,1,3,2],[7,5,7,6],[18,5,18,8],[15,5,15,8],[6,7,6,8],[7,7,7,8],[13,1,13,8],[6,1,6,2],[7,1,7,2],[6,3,6,4],[7,3,7,4],[8,1,10,2],[33,1,35,8],[16,1,16,4],[24,4,24,7],[15,1,15,4],[17,1,18,4],[21,4,23,4],[16,5,16,8],[19,1,20,4],[17,5,17,8],[19,5,19,8]],"flags":["formulas_cached_only"]}
[{"$nulls":7},"様式2(販売）"]
[null,"事業概要報告書"]
[null,"新規申請","更新申請"]
[null,"(いずれかに○をつける)"]
[]
[null,"申　請　事　業　者　の　概　要"]
[null,"設立年月",null,"T・S・H・Ｒ　　年　　月",null,"資本金(基金)",null,"百万円"]
[null,"年間売上高",null,"百万円",null,"総　人　員(注）",null,"人"]
[null,"シルバーサービスの種類・分野"]
[]
[]
[null,"(注1)人数には、パートタイマー、嘱託等非常勤職員を含めてください。"]
[]
[null,"福祉用具販売サービス(本サービス）部門の概要"]
[null,"本サービスの事業開始時期",null,null,null,"　S・H・Ｒ　　　　　　　　　　年　　　　　　月"]
[null,"本サービスを実施している全事業所数",null,null,null,"同左年間売上高実績合計(注1)"]
[null,"事業所",null,null,null,"千円"]
[null,"今回申請する事業所数",null,null,null,"①同左年間売上高実績合計(注2)"]
[{"$nulls":5},"千円"]
[null,"事業所",null,null,null,"②同左年間見込み売上高合計(注3)"]
[{"$nulls":5},"千円"]
[null,"今回申請する事業所の　　　　　　　　　　　　合計従事者内訳",null,null,"サービス従事者","福祉用具専門相談員",null,null,"人"]
[]
[{"$nulls":5},"（内訳　　　常勤　　　　　人・非常勤　　　　　人）"]
[{"$nulls":4},"その他管理・事務等の役職員",null,null,null,"人"]
[{"$nulls":4},"　　　　　合　　　　計",null,null,null,"人"]
[null,"(注1)・直近決算年度(前年度）の売上高実績を記入してください。"]
[null,"(注2)・直近決算年度(前年度）の売上高実績を記入してください。－この売上高が認定手数料を"]
[null,"　　　 算定する基礎数字になります。"]
[null,"       ・今回申請する事業所分について、事業所(福祉用具販売部門）概要・実績報告書（様式6)"]
[null,"        の「直近決算年度(前年度）売上高」を合算して記入してください。"]
[null,"(注3)・今回申請する事業所分について、事業所(福祉用具販売部門）概要・実績報告書（様式6)"]
[null,"        の「見込売上高」を合算して記入してください。"]
[null,"※（注1）（注2）（注3）の売上高は、住宅改造・卸売・医療器具の売上を除く。また、障害者を対象に給付されるオーダーメイド等の義肢・補装具については、売上高が明確に区分できる場合は、当該売上高から除外することとします。"]

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[{"$nulls":7},"様式3(販売）"]
[null,"事　業　計　画　概　要"]
[]
[]
[]
[null,"※記載上の注意"]
[null,"・１、２の項目については申請事業者全体分（複数の事業所を有している場合であって、シルバーマークを申請しない事業所分も含む。）として記入してください。"]
[]
[]
[null,"１．申請する福祉用具販売サービスの「決算年度別事業収支見込み」"]
[null,"項　目",null,"当年度",null,"翌年度",null,"翌々年度"]
[null,"年間売上高①",null,null,"千円",null,"千円",null,"千円"]
[null,"売上原価　②",null,"千円",null,"千円",null,"千円"]
[null,"（商品仕入れ等）"]
[null,"経　費","人件費",null,"千円",null,"千円",null,"千円"]
[null,null,"その他",null,"千円",null,"千円",null,"千円"]
[null,null,"合計　③",null,"千円",null,"千円",null,"千円"]
[null,"利益①－②－③",null,null,"千円",null,"千円",null,"千円"]
[]
[null,"売上高、経費の根拠"]
[]
[null,"（注）申請月が含まれる決算年度を当年度として起算してください。"]
[]
[]
[null,"２．今後の事業展開等"]
[null,"※今後の事業展開について、ご自由にお書きください。"]
[null,"　売上高の増加対策、人数計画、拠点拡大計画、他サービスの展開等"]

{"sheet":"事業所別計画概要3-2(販売）","index":2,"n_rows":32,"n_cols":10,"rows_kept":32,"cut":false,"hidden":false,"merged":[[31,2,31,3],[1,1,1,9],[0,8,0,9],[10,1,10,3],[10,4,10,5],[10,6,10,7],[10,8,10,9],[6,1,7,9]],"flags":["formulas_cached_only"]}
[{"$nulls":8},"様式3-2(販売）"]
[null,"事業所（福祉用具販売部門）計画概要"]
[]
[]
[null,"※記載上の注意"]
[null,"（1）申請する事業所が2以上ある場合、事業所毎にご記入ください。"]
[null,"（2）本用紙をシルバーマークの認定期間中の事業所追加申請として使用する場合は、追加申請する事業所のみをご記入ください。"]
[]
[null,"（3）申請月が含まれる決算年度を当年度として起算して売上高見込をご記入ください。"]
[]
[null,"事　業　所　名",null,null,"当年度見込売上高",null,"翌年度見込売上高",null,"翌々年度見込売上高"]
[{"$nulls":5},"千円",null,"千円",null,"千円"]
[{"$nulls":5},"千円",null,"千円",null,"千円"]
[{"$nulls":5},"千円",null,"千円",null,"千円"]
[{"$nulls":5},"千円",null,"千円",null,"千円"]
[{"$nulls":5},"千円",null,"千円",null,"千円"]
[{"$nulls":5},"千円",null,"千円",null,"千円"]
[{"$nulls":5},"千円",null,"千円",null,"千円"]
[{"$nulls":5},"千円",null,"千円",null,"千円"]
[{"$nulls":5},"千円",null,"千円",null,"千円"]
[{"$nulls":5},"千円",null,"千円",null,"千円"]
[{"$nulls":5},"千円",null,"千円",null,"千円"]
[{"$nulls":5},"千円",null,"千円",null,"千円"]
[{"$nulls":5},"千円",null,"千円",null,"千円"]
[{"$nulls":5},"千円",null,"千円",null,"千円"]
[{"$nulls":5},"千円",null,"千円",null,"千円"]
[{"$nulls":5},"千円",null,"千円",null,"千円"]
[{"$nulls":5},"千円",null,"千円",null,"千円"]
[{"$nulls":5},"千円",null,"千円",null,"千円"]
[{"$nulls":5},"千円",null,"千円",null,"千円"]
[{"$nulls":5},"千円",null,"千円",null,"千円"]
[null,null,"　　　　合　　　　　計",null,null,"千円",null,"千円",null,"千円"]

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[{"$nulls":8},"様式4(販売）№1"]
[null,"福　祉　用　具　販　売　事　業　所　一　覧　表"]
[]
[]
[]
[null,"※記載上の注意"]
[null,"（1）福祉用具販売サービスを行っている全事業所（複数の事業所を有している場合であって、シルバーマークを申請しない事業所分も含む。）をご記入ください。"]
[]
[null,null,"※申請しない事業所については住所は市区郡までの記入で可とし、郵便番号、電話番号、FAX番号は省略しても結構です。"]
[]
[null,"（2）申請対象とする事業所には「申請対象」欄に○印を記入するとともに、該当する「申請区分」欄に○をつけてください。"]
[]
[null,"（3）本用紙をシルバーマークの認定期間中に事業所の追加申請をする際に使用する場合は、追加申請する事業所のみを記入し、新規申請に○をつけてください。"]
[]
[]
[null,"申請対象","申請区分","事　業　所　名",null,"所　　　在　　　地",null,null,null,"備　考"]
[]
[null,null,"新規",null,null,"〒　　　　　－"]
[]
[null,null,"更新"]
[{"$nulls":5},"℡",null,"FAX"]
[null,null,"新規",null,null,"〒　　　　　－"]
[]
[null,null,"更新"]
[{"$nulls":5},"℡",null,"FAX"]
[null,null,"新規",null,null,"〒　　　　　－"]
[]
[null,null,"更新"]
[{"$nulls":5},"℡",null,"FAX"]
[null,null,"新規",null,null,"〒　　　　　－"]
[]
[null,null,"更新"]
[{"$nulls":5},"℡",null,"FAX"]
[null,null,"新規",null,null,"〒　　　　　－"]
[]
[null,null,"更新"]
[{"$nulls":5},"℡",null,"FAX"]
[{"$nulls":8},"様式4(販売）№2"]
[null,"申請対象","申請区分","事　業　所　名",null,"所　　　在　　　地",null,null,null,"備　考"]
[null,null,"新規",null,null,"〒　　　　　－"]
[]
[null,null,"更新"]
[{"$nulls":5},"℡",null,"FAX"]
[null,null,"新規",null,null,"〒　　　　　－"]
[]
[null,null,"更新"]
[{"$nulls":5},"℡",null,"FAX"]
[null,null,"新規",null,null,"〒　　　　　－"]
[]
[null,null,"更新"]
[{"$nulls":5},"℡",null,"FAX"]
[null,null,"新規",null,null,"〒　　　　　－"]
[]
[null,null,"更新"]
[{"$nulls":5},"℡",null,"FAX"]
[null,null,"新規",null,null,"〒　　　　　－"]
[]
[null,null,"更新"]
[{"$nulls":5},"℡",null,"FAX"]
[null,null,"新規",null,null,"〒　　　　　－"]
[]
[null,null,"更新"]
[{"$nulls":5},"℡",null,"FAX"]
[null,null,"新規",null,null,"〒　　　　　－"]
[]
[null,null,"更新"]
[{"$nulls":5},"℡",null,"FAX"]
[null,null,"新規",null,null,"〒　　　　　－"]
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[null,null,"更新"]
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[{"$nulls":8},"様式5(販売）"]
[null,"組　織　概　要　報　告　書"]
[]
[]
[null,"１．事業者全体の組織の概要"]
[null,null,"（※シルバーサービスを統括している本社担当部署、福祉用具販売サービス部門及び今次申請事業所を含めて明示してください。あらかじめ組織図があればそれを添付しても差し支えありません。）"]
{"$rows_empty":14}
[null,"２．福祉用具販売サービス部門の業務分掌"]
[null,null,"（※当該部門の組織図及び業務分掌、管理者名等を記入してください。なお、あらかじめ組織図があればそれを添付しても差し支えありません。）"]

{"sheet":"事業所概要・実績報告書6(販売）","index":5,"n_rows":31,"n_cols":10,"rows_kept":31,"cut":false,"hidden":false,"merged":[[43,1,43,4],[43,5,43,7],[23,3,23,4],[24,3,24,5],[26,1,27,9],[28,1,29,9],[30,1,32,9],[25,3,25,5],[25,6,25,9],[25,1,25,2],[1,1,1,9],[0,8,0,9],[16,6,16,9],[21,3,22,4],[21,5,22,5],[17,4,17,5],[5,1,6,9],[7,1,8,9],[10,1,12,2],[13,1,15,2],[10,3,12,5],[10,6,10,9],[11,6,11,9],[24,1,24,2],[16,4,16,5],[16,3,20,3],[19,4,20,5],[16,1,23,2]],"flags":["formulas_cached_only"]}
[{"$nulls":8},"様式6(販売）"]
[null,"事業所（福祉用具販売部門）概要・実績報告書"]
[{"$nulls":5},"(申請事業所名）"]
[]
[null,"※記載上の注意"]
[null,"（1）申請する事業所毎に作成してください。(申請する事業所が2以上ある場合は、本用紙をコピーの上作成してください。）"]
[]
[null,"（2）本用紙をシルバーマークの認定期間中の事業所追加申請として使用する場合は、追加申請する事業所毎に作成してください。"]
[]
[]
[null,"本サービスの開始時期",null,"S・H・Ｒ　　　　　年　　　　　月",null,null,"介護保険指定事業者（所）番号"]
[{"$nulls":6},"（指定を受けている場合）"]
[{"$nulls":6},"指定番号"]
[null,"本サービスの実施地域　　　　　　　　　　　　　　（市区町村名）"]
[]
[]
[null,"本サービス部門の　　　　　　従事者",null,"サービス従事者","職　種　区　分",null,"備考（資格別内訳等）"]
[{"$nulls":4},"福祉用具専門相談員"]
[{"$nulls":5},"人"]
[{"$nulls":4},"（常勤　　　人・非常勤　　　　人）"]
[]
[null,null,null,"その他管理・事務等の役職員",null,"人"]
[]
[null,null,null,"合　　　計",null,"人"]
[null,"本サービスの事業実績",null,"直近決算年度(前年度）売上高(注1)",{"$nulls":5},"千円"]
[null,"見込売上高(注2)",null,"申請月を含む年度の年間見込売上高",null,null,"千円"]
[null,"(注1)事業概要報告書（様式2(販売））の今回申請する事業所数欄の「①同左年間売上高実績合計」へ合算してください。"]
[]
[null,"(注2)事業概要報告書（様式2（販売））の今回申請する事業所数欄の「②同左年間見込み売上高合計」へ合算してください。"]
[]
[null,"※　売上高について、住宅改造・卸売・医療器具の売上を除きます。また、障害者を対象に給付される、オーダーメイド等の義肢・補装具については、売上高が明確に区分できる場合は売上高から除外することとします。"]

{"sheet":"事業所（福祉用具販売部門）職員名簿7(販売） ","index":6,"n_rows":32,"n_cols":8,"rows_kept":32,"cut":false,"hidden":false,"merged":[[0,7,0,8],[2,5,2,6],[5,1,6,8],[1,1,1,8],[7,1,8,8],[9,1,11,8],[14,3,15,3],[14,4,15,5],[19,0,20,0],[14,6,15,6],[14,7,15,8],[14,0,15,2],[16,0,16,2],[31,0,32,8],[19,1,20,2],[19,7,20,8],[19,3,20,3],[19,4,20,4],[19,6,20,6],[19,5,20,5]],"flags":["formulas_cached_only"]}
[{"$nulls":7},"様式7(販売）№1"]
[null,"事業所（福祉用具販売部門）職員名簿"]
[{"$nulls":5},"（申請事業所名）"]
[]
[null,"※記載上の注意"]
[null,"（1）申請する事業所ごとに作成してください。(申請する事業所が2以上ある場合は、本用紙をコピーの上作成してください。）"]
[]
[null,"（2）本用紙をシルバーマークの認定期間中の事業所追加申請として使用する場合は、追加申請する事業所毎に作成してください。"]
[]
[null,"（3）福祉用具専門相談員が理学療法士、作業療法士、保健師、看護師、准看護師、社会福祉士、介護福祉士又は義肢装具士の場合は、その資格を証するものを添付してください。ただし、更新申請の場合、前回申請時に添付された職員については不要とします。"]
[]
[]
[]
["１．管理者"]
[null,null,null,"社内の　　　　　　役職名","氏　　　　名",null,"配属年月","資　格　等"]
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["管　　理　　者",{"$nulls":5},"年　　月"]
[]
["２．福祉用具専門相談員"]
["№","氏　　　　名",null,"常勤・非常勤別","兼務の　　　　有無","資　　格","配属年月","修了証NO."]
[]
[null,null,null,"常勤　　　　　　　　非常勤","有・無",null,"年　　月"]
[null,null,null,"常勤　　　　　　　　非常勤","有・無",null,"年　　月"]
[null,null,null,"常勤　　　　　　　　非常勤","有・無",null,"年　　月"]
[null,null,null,"常勤　　　　　　　　非常勤","有・無",null,"年　　月"]
[null,null,null,"常勤　　　　　　　　非常勤","有・無",null,"年　　月"]
[null,null,null,"常勤　　　　　　　　非常勤","有・無",null,"年　　月"]
[null,null,null,"常勤　　　　　　　　非常勤","有・無",null,"年　　月"]
[null,null,null,"常勤　　　　　　　　非常勤","有・無",null,"年　　月"]
[null,null,null,"常勤　　　　　　　　非常勤","有・無",null,"年　　月"]
[null,null,null,"常勤　　　　　　　　非常勤","有・無",null,"年　　月"]
["(注）更新申請の場合、前回申請後に採用された職員に対する初任者研修実施の有無状況を記入してください。"]

{"sheet":"福祉用具の品揃え等8-1(販売）","index":7,"n_rows":11,"n_cols":9,"rows_kept":11,"cut":false,"hidden":false,"merged":[[7,1,7,5],[8,1,8,5],[0,7,0,8],[1,1,1,8],[2,1,2,8],[6,1,6,5]],"flags":["formulas_cached_only"]}
[{"$nulls":7},"様式8-1(販売）"]
[null,"事業所における福祉用具の品揃え状況並びに"]
[null,"事業所の構造、面積に関する書類"]
[]
[{"$nulls":6},"事業所名"]
[null,"１．事業所の構造等"]
[null,"店舗面積（売り場・事務所・保管場所を含む）",{"$nulls":6},"㎡"]
[null,"売場面積",{"$nulls":6},"㎡"]
[null,"展示面積（売場面積のうち商品展示部分のみ）",{"$nulls":6},"㎡"]
[null,"店舗の平面図（複数階にわたるものは、全ての階の平面図を記入してください。）"]
[null,"　　※既製の平面図があればそれを転用することで可。"]

{"sheet":"福祉用具の品揃え等8-2(販売）","index":8,"n_rows":78,"n_cols":10,"rows_kept":78,"cut":false,"hidden":false,"merged":[[18,3,18,5],[50,3,50,5],[0,8,0,9],[49,8,49,9],[5,1,5,2],[5,3,5,5],[5,6,5,8],[6,1,18,2],[6,3,10,5],[11,3,14,5],[51,1,60,2],[25,3,27,5],[28,3,34,5],[19,1,34,2],[35,1,48,2],[35,3,36,5],[38,3,42,5],[44,3,47,5],[19,3,24,5],[50,1,50,2],[15,3,17,5],[50,6,50,8],[75,1,76,9],[51,3,52,5],[53,3,57,5],[58,3,60,5],[61,3,64,5],[65,1,74,2],[61,1,64,2]],"flags":["formulas_cached_only"]}
[{"$nulls":8},"様式8-2(販売）（№1）"]
[null,"２．品揃えの状況"]
[]
[null,"（注1）現品展示の有無について、確認欄に○印を付してください。"]
[null,"（注2）例示商品以外の商品を展示している場合は、その他欄に記載してください。"]
[null,"機　　　能",null,"用　途　分　類",null,null,"商　品　例",null,null,"確認欄"]
[null,"１．排泄関係",null,"①トイレ機器用品",null,null,"・腰掛便座",null,null,"有・無"]
[{"$nulls":6},"（ポータブルトイレ含む）"]
[{"$nulls":6},"・便座、便器",null,null,"有・無"]
[{"$nulls":6},"・特殊尿器",null,null,"有・無"]
[{"$nulls":6},"・尿器",null,null,"有・無"]
[null,null,null,"②おむつ関連用品",null,null,"・紙おむつ",null,null,"有・無"]
[{"$nulls":6},"・おむつカバー",null,null,"有・無"]
[{"$nulls":6},"・失禁用パンツ",null,null,"有・無"]
[{"$nulls":6},"・その他",null,null,"有・無"]
[null,null,null,"③トイレ・おむつ周辺商品",null,null,"・消臭用品",null,null,"有・無"]
[{"$nulls":6},"・その他小物",null,null,"有・無"]
[{"$nulls":6},"（スキンケアクリーム等）",null,null,"有・無"]
[null,null,null,"➃その他",null,null,"・排泄予測支援機器",null,null,"有・無"]
[null,"２．入浴関連",null,"①入浴補助用具",null,null,"・入浴用いす",null,null,"有・無"]
[{"$nulls":6},"・浴槽用いす",null,null,"有・無"]
[{"$nulls":6},"・浴槽内いす",null,null,"有・無"]
[{"$nulls":6},"・入浴台",null,null,"有・無"]
[{"$nulls":6},"・浴室内すのこ",null,null,"有・無"]
[{"$nulls":6},"・浴槽内すのこ",null,null,"有・無"]
[null,null,null,"②部分浴用品",null,null,"・洗髪器",null,null,"有・無"]
[{"$nulls":6},"・洗足器",null,null,"有・無"]
[{"$nulls":6},"・局部洗浄器",null,null,"有・無"]
[null,null,null,"③その他",null,null,"①簡易浴槽",null,null,"有・無"]
[{"$nulls":6},"②その他の入浴小物"]
[{"$nulls":6},"・滑り止めマット（シート）",null,null,"有・無"]
[{"$nulls":6},"・清拭剤",null,null,"有・無"]
[{"$nulls":6},"・シャンプーハット",null,null,"有・無"]
[{"$nulls":6},"その他（入浴用エプロン、",null,null,"有・無"]
[{"$nulls":6},"　　　　　　ドライシャンプー等）"]
[null,"３．移動機器関連",null,"①手動車いす",null,null,"・普通型車いす",null,null,"有・無"]
[{"$nulls":6},"・介助型車いす",null,null,"有・無"]
[null,null,null,"②車いす付属品",null,null,"・車いす用クッション等",null,null,"有・無"]
[null,null,null,"③歩行補助杖",null,null,"・ステッキ",null,null,"有・無"]
[{"$nulls":6},"・T型杖",null,null,"有・無"]
[{"$nulls":6},"・松葉杖",null,null,"有・無"]
[{"$nulls":6},"・多脚型杖",null,null,"有・無"]
[{"$nulls":6},"・その他の杖",null,null,"有・無"]
[null,null,null,"④歩行補助杖付属品",null,null,"・杖の先のゴム",null,null,"有・無"]
[null,null,null,"⑤歩行器・歩行車",null,null,"・固定歩行器",null,null,"有・無"]
[{"$nulls":6},"・４輪歩行器",null,null,"有・無"]
[{"$nulls":6},"・買い物型歩行車",null,null,"有・無"]
[{"$nulls":6},"・その他の歩行器",null,null,"有・無"]
[null,null,null,"⑥その他",null,null,"・移動用リフトのつり具の部分",null,null,"有・無"]
[{"$nulls":8},"様式8-2(販売）（№2）"]
[null,"機　　　能",null,"用　途　分　類",null,null,"商　品　例",null,null,"確認欄"]
[null,"４．特殊寝台関連",null,"①特殊寝台",null,null,"・ギャッジ型ベッド（背起き）",null,null,"有・無"]
[{"$nulls":6},"・ハイロー型ベッド",null,null,"有・無"]
[null,null,null,"②特殊寝台付属品",null,null,"・ベッド用テーブル",null,null,"有・無"]
[{"$nulls":6},"・ベッド併設移動カバー",null,null,"有・無"]
[{"$nulls":6},"・サイドレール",null,null,"有・無"]
[{"$nulls":6},"・その他（マットレス、防水シーツ、",null,null,"有・無"]
[{"$nulls":6},"枕等）"]
[null,null,null,"③褥瘡予防用具",null,null,"・エアーマット",null,null,"有・無"]
[{"$nulls":6},"・ビーズマット",null,null,"有・無"]
[{"$nulls":6},"・その他の褥瘡予防用具",null,null,"有・無"]
[null,"５．衣類関係用品",null,"①衣類関係用品",null,null,"・寝間着",null,null,"有・無"]
[{"$nulls":6},"・下着、肌着",null,null,"有・無"]
[{"$nulls":6},"・食事用エプロン",null,null,"有・無"]
[{"$nulls":6},"・リハビリシューズ等",null,null,"有・無"]
[null,"６．その他"]
{"$rows_empty":9}
[null,"（注）介護保険の下での適切なサービス提供の観点から下線のある特定福祉用具対象項目については品揃えがあることが望ましい。"]
[]
[null,"　　食事関連用品（食器、橋、スプーン等）についても品揃えがあることが望ましい。"]

{"sheet":"異動・変更届（販売）","index":9,"n_rows":52,"n_cols":12,"rows_kept":52,"cut":false,"hidden":false,"merged":[[23,7,23,11],[16,1,16,2],[17,1,17,2],[35,1,35,2],[29,3,29,6],[29,7,29,11],[1,0,1,11],[23,1,29,2],[32,3,32,6],[32,7,32,11],[2,10,2,11],[36,1,36,2],[14,1,15,2],[13,3,13,6],[13,7,13,11],[23,3,23,6]],"flags":["formulas_cached_only"]}
[{"$nulls":11},"(販売）"]
["変　更 ・ 異　動　等　届"]
[{"$nulls":10},"令和　　年　　月　　日"]
[null,"一般社団法人シルバーサービス振興会理事長　　殿"]
[{"$nulls":6},"事業者名"]
[{"$nulls":6},"代表者名",{"$nulls":4},"印"]
[{"$nulls":6},"現在の認定番号　Ｓ　（　　　　　）"]
[]
[null,"次の事項について、令和　　年　　月　　日付にて変更・異動等がありましたので、お届けいたします。"]
[null,"　（１～５のうち、該当する番号に○をつけてください。）"]
[]
["１．氏名又は名称及び住所の変更"]
[null,"（１）本社所在地、事業者名、代表者名（該当項目に○をつけてください。）"]
[null,null,null,"変　　更　　前",null,null,null,"変　　更　　後"]
[null,"本社所在地",null,"〒　　　－",null,null,null,"〒　　　－"]
[]
[null,"事業者名"]
[null,"代表者名"]
[null,"電話等",null,"℡",null,null,"Fax","℡",null,null,"Fax"]
[null,null,"※添付書類 ・所在地、事業者名のときは「登記簿謄本」"]
[null,null,null,"　　     ・代表者の時は「登記簿謄本」と「履歴書」"]
[]
[null,"（２）申請窓口、郵便物等の送付先（該当項目に○をつけてください。）"]
[null,"窓口・送付先",null,"変　　更　　前",null,null,null,"変　　更　　後"]
[null,null,null,"〒　　　－",null,null,null,"〒　　　－"]
[null,null,null,"（住所）",null,null,null,"（住所）"]
[null,null,null,"（法人名・担当部署）",null,null,null,"（法人名・担当部署）"]
[null,null,null,"（担当者名）",null,null,null,"（担当者名）"]
[null,null,null,"℡",null,null,"Fax","℡",null,null,"Fax"]
[null,null,null,"メールアドレス",null,null,null,"メールアドレス"]
[]
[null,"（３）事業所の所在地・移転、事業所名の変更（該当項目に○をつけてください。）"]
[null,null,null,"変　　更　　前",null,null,null,"変　　更　　後"]
[null,"所在地",null,"〒　　　－",null,null,null,"〒　　　－"]
[]
[null,"事業所名"]
[null,"電話等",null,"℡",null,null,"Fax","℡",null,null,"Fax"]
[null,null,"※添付書類 ・「福祉用具販売事業所一覧表」（様式4（販売））"]
[null,null,null,"　　 　  ・事業所移転のときは、「事業所における福祉用具の品揃え状況並びに事業所の構造、面積に関する"]
[null,null,null,"           書類」（様式８） 、写真（外観１～2枚）と行き方のわかる付近図"]
[]
["２．管理者及びサービス従事者（福祉用具専門相談員）の異動"]
[null,null,"※添付書類  「事業所（福祉用具販売部門）職員名簿」（様式7（販売）で示す添付書類を含む。）"]
[null,null,null,"　 　　　  　　（異動前、異動後の対象者がわかるように記入してください。）"]
["３．事業所の本サービスの廃止、閉鎖等"]
[null,"（廃止の理由）"]
[]
["４．認定の返上"]
[null,"（返上の理由）"]
["５．その他事業者の企業・団体再編等"]
[null,"（上記の理由）"]
[null,null,"※添付書類　　上記理由を証する書面"]