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[null,"学生の地域連携活動　助成申請書",{"$nulls":6},"様式1"]
[{"$nulls":4},"申請日：","平成　　　年　　月　　日"]
["下記のとおり申請いたします。",null,null,null,"申請区分","新規　・　継続　（　　）年目"]
["活動団体名",{"$nulls":4},"担当教員","　　　　　　　　印"]
["活動に参加する\n学生代表者","所属学科","学科",null,null,"学年","年"]
[null,"氏名",null,null,null,"学籍番号"]
[null,"ＴＥＬ\n（携帯）"]
[null,"メール\nアドレス"]
["この活動の\n活動歴","初めて　　・　（　　　　）年目",null,null,"参加学生数\n（学籍番号・学科・学年・氏名を記載した名簿を添付すること）",null,null,"名"]
["活動のねらい"]
["活動内容\n（資料があれば添付すること）"]
["連携先","名称",null,null,null,"代表者名"]
[null,"住所"]
[null,"電話番号",null,null,"アドレス"]
["活動\nスケジュール"]
["活動によって開発しようとするサービス・商品"]
[{"$nulls":4},"※提出時は両面印刷を行ってください"]
[null,"収支予算"]
["申請額",{"$nulls":4},"円（最高15万円まで）"]
["収入","経費項目",null,"金　　　　額（円）",null,"備考"]
[null,"（a）学生による地域連携活動助成",null,null,null,"※上記申請額と同額"]
[null,"（ｂ）",null,null,null,"※部費や他に助成を受けている場合はそれぞれ直近のもの（部費は昨年度実績）を（ｂ）に記入してください）"]
[]
[]
[null,"合計（a）+（ｂ）",null,0]
["支出","経費項目",null,"金　　　　額（円）",null,"内容"]
[null,"消耗品"]
[null,"交通費"]
[null,"謝金"]
[]
[]
[]
[]
[]
[null,"合計",null,0,null,"※収入合計額と同額になること"]
["特記事項"]
{"$rows_empty":7}
[{"$nulls":4},"※提出時は両面印刷を行ってください"]