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["サンプルご依頼書"]
["※太枠の中をご記入いただき、ＦＡＸ(058-252-5115)またはメール(info@riceisland.co.jp)で"]
["お送りください。直送の場合は、お送り先についてもご記入をお願いいたします。 　　    *入力必須項目"]
[{"$nulls":4},"ご依頼日　　　　　　　年　　　　月　　　　日"]
["依頼者情報"]
[1,"貴社名",{"$nulls":4},"*"]
[2,"担当者氏名",{"$nulls":4},"*"]
[3,"部署名",null,null,"4 役職名　　"]
[5,"郵便番号"]
[6,"住所",{"$nulls":4},"*"]
[7,"電話番号",{"$nulls":4},"*"]
[8,"e-mail",{"$nulls":4},"*"]
[9,"業種","※該当する業種に◯をつけてください。",null,null,null,"*"]
[null,null,"食品卸   原料卸   米卸   食材卸   製菓製パン卸   外食   給食   惣菜   ベンダー   弁当   ホテル"]
[null,null,"製粉   製パン   メーカー   小売   健食   受託   通販   訪販   商社   マスコミ   その他（　　　　　　）"]
[]
[10,"サンプル希望","※複数選択可",null,null,null,"*"]
[null,null,"Ａ 外食原材料     Ｂ 健康指向素材     Ｃ メーカー向け原料\nＤ 菓子/パン原料     Ｅ お茶     Ｆ ファイン加工豆     Ｇ おすすめ商品"]
[null,null,"※サンプル内容は別紙をご参照ください。また、内容は在庫状況などにより予告なく変更になる場合がございます。"]
[11,"用途","※用途は必ずご記入ください。",null,null,null,"*"]
[]
[12,"備考","※上記選択肢以外のサンプルがご希望の場合は、下記に国産、輸入、規格、商品名、数量をご記入ください。"]
[]
[]
[]
["※直送の場合のお届け先"]
[13,"会社名"]
[14,"氏名"]
[15,"部署名",null,null,"4 役職名　　"]
[17,"郵便番号"]
[18,"住所"]
[19,"電話番号"]
[20,"業種","※該当する業種に◯をつけてください。"]
[null,null,"食品卸   原料卸   米卸   食材卸   製菓製パン卸   外食   給食   惣菜   ベンダー   弁当   ホテル"]
[null,null,"製粉   製パン   メーカー   小売   健食   受託   通販   訪販   商社   マスコミ   その他（　　　　　　）"]
["【注意事項】"]
["・発送日はお問い合せ下さい。"]
["・ヤマト運輸のメール便でお送りいたします。着日指定は受け付けておりません。"]
["・サンプルによっては、送料、商品代をご負担頂く場合があります。"]
[null,"弊社記入欄"]
[null,"発送日"]
[null,"手配担当"]
[null,"備考"]
[]
[]
[null,"〒500-8322  岐阜市香取町3丁目38番地　TEL　058-253-0303　FAX　058-252-5115"]
[]
[]
[null,"サンプル内容一覧"]
[null,"サンプルセット名",null,"商品名",null,"産地"]
[null,"Ａ","外食原材料","おいしい麦",null,"国産"]
[null,null,null,"おいしい玄米",null,"国産"]
[null,null,null,"きき麦",null,"国産"]
[null,null,null,"黒米",null,"国産"]
[]
[null,"Ｂ","健康指向素材","大麦フレーク",null,"輸入"]
[null,null,null,"大豆フレーク",null,"輸入"]
[null,null,null,"全穀粉",null,"輸入"]
[null,null,null,"ポンセン",null,"国産・輸入"]
[]
[null,"Ｃ","メーカー向け原料","キヌア",null,"輸入"]
[null,null,null,"アマランサス",null,"輸入"]
[null,null,null,"きび",null,"輸入"]
[null,null,null,"あわ",null,"輸入"]
[null,null,null,"ひえ",null,"輸入"]
[null,null,null,"べっぴん十六穀",null,"輸入"]
[]
[null,"Ｄ","菓子/パン原料","もっちり五穀黒ごま麦",null,"輸入"]
[null,null,null,"香る五穀金麦きび",null,"輸入"]
[null,null,null,"国産ファイン加工雑穀",null,"国産"]
[null,null,null,"たまご色ホッブレンド",null,"輸入"]
[null,null,null,"さくらビューティブレンド",null,"輸入"]
[null,null,null,"黒力チャージブレンド",null,"輸入"]
[null,null,null,"ライ麦",null,"国産"]
[]
[null,"Ｅ","お茶","はと麦",null,"輸入"]
[null,null,null,"とうもろこし",null,"輸入"]
[null,null,null,"だったんそば",null,"輸入"]
[null,null,null,"大麦",null,"輸入"]
[]
[null,"Ｆ","ファイン加工豆","黒大豆",null,"輸入"]
[null,null,null,"大豆",null,"国産"]
[null,null,null,"小豆",null,"国産"]
[]
[null,"Ｇ","おすすめ商品","ひえ麺",null,"輸入"]
[null,null,null,"米粉",null,"国産"]
[null,null,null,"大麦粉",null,"国産"]
[]
[null,"※サンプル内容については、在庫状況などにより若干異なる場合がございます。"]