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sample
以下の内容でメールを送信します
■お名前※

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姓   名 
全角漢字でご入力ください

■フリガナ※

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セイ   メイ 
全角カタカナでご入力ください

■生年月日※

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■性別

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■郵便番号※

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 - 

■都道府県※
・都道府県

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・市区町村

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・丁目・番地

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アパート・マンション名等

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■ご連絡先
・電話番号

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・携帯電話

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・メールアドレス※

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■アンケートにご協力ください
・このページは良かったですか?

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・どのような環境でインターネットをご利用ですか?(複数回答可)

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■ご意見・ご質問がございましたらご入力ください。

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