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["介護おむつネット　介護施設様用　ＦＡＸ注文書"]
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["お申込み専用 ＦＡＸ番号　０１２０－３９－５３６４（通信料無料）"]
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["施設名",{"$nulls":4},"ご住所","〒　　　　-"]
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["◆ご発注内容",{"$nulls":4},"電話番号",null,null,"ご担当者名"]
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["商品名",null,null,null,"単品・箱","数量","価格",null,"備考"]
[{"$nulls":4},"単品・箱"]
[{"$nulls":4},"単品・箱"]
[{"$nulls":4},"単品・箱"]
[{"$nulls":4},"単品・箱"]
[{"$nulls":4},"単品・箱"]
[{"$nulls":4},"単品・箱"]
[{"$nulls":4},"単品・箱"]
[{"$nulls":4},"単品・箱"]
[{"$nulls":4},"単品・箱"]
[{"$nulls":4},"単品・箱"]
[{"$nulls":4},"単品・箱"]
[{"$nulls":4},"単品・箱"]
["●手数料　（代引きの場合）　\nご購入金額合計7,000円未満は330円、7,000円以上は無料"]
["●送料（税込・一部ご負担）\n※地域ごとに変わります。下記を確認ください。\n\n　北海道：1,760円\n　東北地方：990円\n　関東・信越・北陸・中部地方：770円\n　関西・中国・四国・九州地方：550円\n　沖縄県：2,090円"]
["　",null,null,null,"合計","点","円"]
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["◆お支払",null,"当てはまるものにチェックをしてください。"]
["お支払方法　□代引　　□振込 もみじ銀行　□振込 ＪＡ  □振込 ゆうちょ　"]
["□一括でのお支払",null,null,"名義"]
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["□複数名で分割",null,null,"複数の方で分割払いにされる場合、下記に金額をご記入ください。\n※代引手数料については、均等割りするか、どなたかが負担するかを、下記に配分して記載ください。"]
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[null,"お名前",null,null,"分割金額",null,null,"備考"]
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["※消費税の端数計算方式の差異により、ご記入いただいた金額と実際の金額が異なる場合がございます。その際はお知らせ致します。"]