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["退　社　連　絡　票　"]
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["退職後",null,null,null,"ﾌﾘｶﾅ\n〒",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"TEL"]
[null,null,null,null,"〒"]
["の住所",null,null,null,"(          )"]
["退社年月日",null,null,null,null,null,null,null,null,null,null,null,"退職理由",null,null,"自己都合　・　契約期間満了　・　解　雇\n・　その他（　　　　　　　　　　　　　　　　）"]
["雇  用  期  間",null,null,null,null,null,null,null,null,"平成      年　  　月  　　日  ～  平成　  　年　  　月　  　日"]
["離職票の交付",null,null,null,null,null,null,null,null,"　　　必　要　　　・　　　不　要　　\n　※　離職票が必要な場合は、賃金台帳を添付または賃金支払対象期間等に記入"]
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["給 与 の 形 態",null,null,null,null,null,"     月　給　・　日　給　・　時間給　・　その他（　　　　　）"]
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[null,null,null,null,null,null,null,null,null,null,null,null,null,"無","(紛失・未提出）"]
["健 康 保 険 被 保 険 者 証",null,null,null,null,null,null,null,null,null,null,null,null,"有","(添付）",null,null,null,null,null,"被保険者番号"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"無","(紛失・未提出）"]
[]
["離職の日以前（被保険者区分変更の日前）の賃金支払状況等"]
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["入　社　連　絡　票"]
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["氏　名",null,null,null,null,null,null,null,null,null,null,null,"男・女",null,"月　日"]
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["現住所"]
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["職　種",null,null,null,"１管理的職業、２専門的技術的職業、３事務的職業、４販売の職業、５サービスの職業、６保安の職業、"]
[null,null,null,null,"７農林漁業、８生産工程の職業、９輸送、機械運転の職業、10建設採掘の職業、11運搬清掃包装等の職業"]
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[null,null,"被 扶 養 者 氏 名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"別　居",null,"(職業・学校学年）"]
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[null,"氏名"]
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[null,"氏名"]
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["雇 用 期 間",null,null,null,null,null,"無 ・ 有（令和　　年　 　月 　　日 ～ 令和　 　年　 　月　 　日）"]
["職歴","会　社　名",null,null,null,null,null,null,null,null,null,null,null,null,"勤　務　年　月"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　　　　年　　　月　～　　　　　　年　　　　月"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　　　　年　　　月　～　　　　　　年　　　　月"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　　　　年　　　月　～　　　　　　年　　　　月"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　　　　年　　　月　～　　　　　　年　　　　月"]
["社会保険の加入",null,null,null,null,null,null,null,"厚生年金　　　　健康保険　　　　雇用保険         "]
["厚 生 年 金 被 保 険 者 証",null,null,null,null,null,null,null,null,null,"有","(添付）",null,null,null,null,null,"基礎年金番号"]
[null,null,null,null,null,null,null,null,null,null,"無","(紛失・未提出）"]
["雇 用 保 険 被 保 険 者 証",null,null,null,null,null,null,null,null,null,"有","(添付）",null,null,null,null,null,"被保険者番号"]
[null,null,null,null,null,null,null,null,null,null,"無","(紛失・未提出）"]
[]
[null,null,null,"月給　・　日給　・　時間給"]
[null,null,null,"基　　本　　給　　　　",null,null,null,null,null,null,null,null,null,"円",null,null,null,"手当",null,null,null,null,null,null,"円"]
[null,null,null,null,null,null,"手当",null,null,null,null,null,null,"円",null,null,null,"通勤手当",null,null,null,null,null,null,"円"]
[null,null,null,null,null,null,"手当",null,null,null,null,null,null,"円"]
[null,null,null,null,null,null,"手当",null,null,null,null,null,null,"円"]
[]
[null,null,null,null,null,null,null,null,null,null,null,"1ヶ月の給与総額（見込）",null,null,null,null,null,null,null,null,null,null,null,null,"円"]
[]
["　備　考"]