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["別紙様式第 1 号（第 10 条第 2 項関係）"]
["特定歴史公文書等利用請求書"]
["年　　    月　    日"]
["東京工業大学博物館資史料館部門長   殿"]
[]
["氏名又は名称： （法人その他の団体にあってはその名称及び代表者の氏名）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"住所又は居所： （法人その他の団体にあっては主たる事務所等の所在地）"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"〒　　　　　　　　　　　　　　　　　　　　　　　　TEL　　　(　　)"]
["連絡先：（連絡先が「氏名又は名称」欄に記載された本人以外の場合は，連絡担当者の住所・氏名・電話番号）"]
["〒　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　TEL　　　　(　　)"]
[]
["公文書等の管理に関する法律第 16  条の規定に基づき，下記のとおり特定歴史公文書等の利用を請求します。"]
["No.",null,"識別番号",null,null,null,null,null,"目録に記載された特定歴史公文書等の名称\n※写しの交付の範囲を特定する場合は〔  〕内に該当部分を特定できる情報\n（件名その他）を記載のこと \n(例：○○に関する部分，○○に関する件)",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,"利用方法\n（任意）",null,null,null,null,null,null,"公文書室記入欄\n（制限区分）"]
[]
[]
[1,null,null,null,null,null,null,null,"ファイル名",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,"閲覧",null,null,null,null,null,null,"要審査"]
[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,null,null,null,null,null,null,null,null,null,null,null,"一部利用可"]
[null,null,null,null,null,null,null,null,"※件名等",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,"写しの交付(　通)",null,null,null,null,null,null,"全部利用可"]
[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,null,null,null,null,null,null,null,null,null,null,null,"非公開"]
[2,null,null,null,null,null,null,null,"ファイル名",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,"閲覧",null,null,null,null,null,null,"要審査"]
[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,null,null,null,null,null,null,null,null,null,null,null,"一部利用可"]
[null,null,null,null,null,null,null,null,"※件名等",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,"写しの交付(　通)",null,null,null,null,null,null,"全部利用可"]
[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,null,null,null,null,null,null,null,null,null,null,null,"非公開"]
[3,null,null,null,null,null,null,null,"ファイル名",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,"閲覧",null,null,null,null,null,null,"要審査"]
[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,null,null,null,null,null,null,null,null,null,null,null,"一部利用可"]
[null,null,null,null,null,null,null,null,"※件名等",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,"写しの交付(　通)",null,null,null,null,null,null,"全部利用可"]
[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,null,null,null,null,null,null,null,null,null,null,null,"非公開"]
[4,null,null,null,null,null,null,null,"ファイル名",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,"閲覧",null,null,null,null,null,null,"要審査"]
[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,null,null,null,null,null,null,null,null,null,null,null,"一部利用可"]
[null,null,null,null,null,null,null,null,"※件名等",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,"写しの交付(　通)",null,null,null,null,null,null,"全部利用可"]
[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,null,null,null,null,null,null,null,null,null,null,null,"非公開"]
["写しの交付媒体 （任意）",null,null,null,null,null,null,null,null,"用紙への印画による交付（A4・B4・A3  ）"]
[null,null,null,null,null,null,null,null,null,"電磁的記録として交付（CD-R/DVD-Rによる）"]
["写しの交付の方法",null,null,null,null,null,null,null,null,"館において交付",null,null,null,null,null,null,"郵送（送付先　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　）"]
[]
["※注１：写しの作成方法及び部数については，写しの交付による利用を希望する場合のみ記入してください。"]
["※注２：写しの交付に係る手数料は，作成方法（原本からの撮影または複製物からの複写）および交付媒体（用紙への印画・電磁的記録としての複写）等によって異なります。"]