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["　(V1-2様式)",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,"VIA　2024.4"]
[null,null,null,null,null,"四 輪 自 動 車 試 験 依 頼 書",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"受　　付","受付日",null,null,null,null,null,null,null,"年","受 付 印"]
[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,"月",null,null,"日"]
[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,"排出ｶﾞｽ",null,null,"№"]
[null,"一般財団法人　日本車両検査協会　　殿",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,"加速騒音",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,"※上記枠内は記入しないで下さい。"]
[]
[null,null,"別紙の自動車排出ｶﾞｽ試験及び加速走行騒音試験等のご案内を了承のうえ下記の試験を依頼します。"]
[null,null,null,"※この依頼書は依頼事項 1件 につき １部 になります。",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,"年",null,null,"月",null,null,"日"]
[null,null,"（排出ガス試験と加速騒音試験を同時に依頼される場合、依頼書は2部ご提出下さい。)"]
[null,"試験依頼者"]
[null,null,null,null,null,"〒",null,null,null,"-",null,null,null,"TEL",null,null,null,null,null,null,null,null,null,null,null,null,"FAX"]
[null,"住　　所"]
[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,"氏　　名"]
[null,"又は名称",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,"※必ず押印下さい。"]
[]
[null,"車　　　　　　名",null,null,null,null,null,null,null,null,null,null,null,null,"型式又は車両種別",null,null,null,null,null,null,null,null,null,null,null,"車台番号（シリアル番号）"]
[]
[]
[null,"該当箇所に○を記入して下さい。　"]
[null,"輸入者名（並行輸入車試験時）\nもしくは改造内容（改造車での試験時）",null,null,null,null,null,null,null,null,null,null,null,null,"試 験 区 分 （ 排 ｶﾞ ｽ ）",null,null,null,null,null,null,null,null,null,null,null,"駆 動 輪",null,null,null,null,"燃料の種類"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"並行輸入",null,null,null,null,null,"NOx・PM法",null,null,null,null,null,"前　輪",null,null,null,null,"ｶﾞｿﾘﾝ",null,null,null,"C N G"]
[]
[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,"後　輪",null,null,null,null,"軽　　油",null,null,null,"L P G"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"改造",null,null,null,null,null,"その他 ※"]
[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,"全　輪",null,null,null,null,"水素",null,null,null,"その他"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"試 験 区 分 （ 加 速 走 行 騒 音 ）",null,null,null,null,null,null,null,null,null,null,null,"変速機",null,null,null,null,"車 両 重 量"]
[null,"排出ガス\n規制年度",null,null,null,"昭和",null,null,null,null,null,"年規制",null,null,null,"細目告示別添40",null,null,null,null,null,"協定規則第51号",null,null,null,null,null,"AT",null,null,null,null,null,null,null,null,null,"kg"]
[null,null,null,null,null,"平成",null,null,null,null,null,null,null,null,"用  途",null,null,null,null,null,null,null,null,null,null,null,null,"MT"]
[null,null,null,null,null,"令和",null,null,null,null,null,null,null,null,null,"乗用",null,null,"貨物",null,null,"特種",null,null,"乗合",null,null,"CVT"]
[null,"粒子状物質",null,null,null,null,null,null,"試験項目(ﾓｰﾄﾞ）"]
[null,null,null,"PM測定",null,null,null,null,null,"WLTC",null,null,null,null,null,"WHTC",null,null,null,null,null,"10.15+JC08C",null,null,null,null,null,"10.15 / 11",null,null,null,null,"10.15M のみ",null,null,null,null,"13M"]
[null,null,null,"PN測定",null,null,null,null,null,"JC08H+JC08C　",null,null,null,null,null,"JE05",null,null,null,null,null,"10.15 + 11",null,null,null,null,null,"10 / 11",null,null,null,null,"10M のみ",null,null,null,null,"6M"]
[null,"騒音防止性能確認標章の有無（加速走行騒音）",null,null,null,null,null,null,null,null,null,null,null,null,"整備・対策の完了日",null,null,null,null,null,"試験場所",null,null,null,null,null,"試験成績書受領方法"]
[null,null,"有",null,null,"無",null,"試験合格時",null,null,null,null,null,null,null,null,"月",null,null,"日",null,"東京検査所",null,null,null,null,null,"手渡し",null,null,null,null,null,"宅急便（着払い）"]
[null,null,null,null,null,null,null,"（有料 1,100円）",null,null,null,null,null,null,"以降受験可能",null,null,null,null,null,null,"大阪検査所",null,null,null,null,"※ ○の無い場合は依頼者宛に着払い宅急便"]
[null,"試験日通知等の試験担当連絡者氏名、電話番号、FAX番号",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※　注",null,null,null,null,null,"　　にて発送させていただきます。"]
[null,"氏名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"１．","受付時に他の申請必要書類と共にご提出下さい。\nこの依頼書受付後のｺﾋﾟｰが控え及び受験票となります。"]
[]
[null,"TEL",null,null,null,null,null,null,null,null,null,"FAX",null,null,null,null,null,null,null,null,"２．","並行輸入車は諸元表、通関証明書原本（確認後返却）、その他は諸元表、車検証、抹消証、完成検査証等のコピーが必要です。"]
[null,"試験料金銀行振込名義（試験依頼者、輸入者以外の場合）"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"３．","自動変速機（AT車）については、6モード及び13モードの排出ガス試験は実施できません。"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"４．","平成５年規制以降のﾃﾞｨｰｾﾞﾙ車及び平成２１年規制（ﾎﾟｽﾄ新長期）の、NOx触媒付ｶﾞｿﾘﾝ直噴車はPM測定が必要となり、料金が異なります。\n"]
[null,"宅急便による送り先（上記依頼者以外の場合）"]
[null,"〒",null,null,null,null,"-",null,null,null,"TEL"]
[null,"住所",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"５．","令和5年5月１日以降のガソリン直噴車（ストイキ）についてはＰＭ規制が適用されますので、事前に自動車技術総合機構の各事務所に確認のうえご依頼ください。"]
[null,"氏名又は　　　　　　　　　　　　　　　　　　　　　　　　名　称"]
[]
[null,"備　考","　※試験区分にて、その他を選択された方は内容をご記入ください。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"手数料（円）",null,null,null,null,null,null,"領収印"]
[]
[]
[]
[]
[null,"- - - - - - - - - - - - - - - - - - - - - 協　会　記　入　欄　（下記枠内には記入しないで下さい） - - - - - - - - - - - - - - - - - - - - -"]
[null,"試験月日",null,null,null,"成績書番号",null,null,null,null,null,null,null,"所　長",null,null,"次　長",null,null,"主　任",null,null,null,"係　員",null,null,"触\n媒",null,"ﾒｰｶｰ純正"]
[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,"その他"]
[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,"区\n分"]

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