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["编号"]
["营业执照号码"]
["单位名称"]
["单位地址",{"$nulls":6},"邮编"]
["法定代表人",null,null,"负责人"]
[null,null,"假肢和矫形器（辅助器具）生产装配企业资格认定证书号码"]
["注册资本","（万元）",null,"所有制形式"]
["联系人",null,null,"联系电话"]
["辅助器具配置 场地状况","所在地"]
[null,"提供方式","□自有产权□租借 □无偿提供",null,null,"使用年限"]
[null,"产权或使用权归属",{"$nulls":3},"面积",null,null,"（平米）"]
[null,"假肢取模室、修模室、接受腔制作成型室、打模室、装配室、功能训练室面积（平米）："]
[null,"为工伤辅具器具配置提供服务床位数"]
["设备状况","名称",null,"型号","数量",null,"备注"]
[]
[]
[]
[]
[]
["设备状况","型号",null,"数量","用途",null,"备注"]
[]
[]
[]
[]
["从业人员状况","人员姓名","专业名称","技术等级","从业时间",null,"备注"]
[]
[]
[]
[]
[]
["申请理由"]
["申请单位意见","法定代表人（负责人）签字：  （盖章）  年 月 日"]
["市社保经办机构 材料审查情况","审查人签字： （盖章）负责人签字： 年 月 日"]
["市社保经办机构评估意见","负责人签字： （盖章） 年 月 日"]
["说明："]
["说明：\n\n一、本申请书一式两份，由市社保经办机构和申请单位分别留存。\n\n二、申请成为工伤职工配置制氧机机构应当填写本申请书，其中“假肢和矫形器（辅助器具）生产装配企业资格认定证书号码”填写“第二类医疗器械经营备案凭证或医疗器械生产企业许可证号码”，“辅助器具配置场地状况”只填写提供方式、使用年限、产权或使用权归属和面积，“设备状况”填写制氧机信息。"]