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["　　　"]
[null,"㈱髙島屋クレイキャピタル",null,null,null,null,null,null,null,null,null,null,"　融　資 申 込 書",null,null,null,null,null,null,null,null,null,null,null,null,null,"申込FAX番号048-682-2302"]
[null,null,null,null,null,null,null,null,null,null,null,"（新　規　取　引　用）"]
[null,null,"当社は貴社に対する次の融資申し込みにつき以下の通り申告いたします。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"申込年月日　　　　　　　　　 年　　　　月　　　　日"]
[null,null,"申込区分（ご希望の営業品目を選択してください）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"融資希望日",null,null,null,null,null,null,"融資希望額"]
[null,null," □無担保融資　　□不動産　□保証人　□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,null,"万円"]
[]
[null,null,"１.申込人の事業内容についてについてご記入ください。"]
[null,null,"申　込　人　の　商  号  又  は  屋  号",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"㊞",null,null,null,"創　業　又　は　設　立　年　月"]
[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,"□創業"]
[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,"□設立",null,"　　　　　　　　　 　　　　　　年　　　　　　月"]
[null,null,"本店所在地　    　　　       　　 □自己所有  □親族所有　□賃貸",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"登記上の本店　　 □自己所有  □親族所有　□賃貸"]
[null,null,"〒",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"□本店所在地に同じ　　　　　　　　　　都道　　　　　　　　市町"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"□本店所在地と異なる　　　　　　　　　府県　　　　　　　　区村"]
[null,null,"代 表 電 話 番 号　",null,null,null,null,null,null,null,null,null,"Ｆ Ａ Ｘ 番 号",null,null,null,null,null,null,null,null,null,"当　座　預　金",null,null,null,null,null,null,null,"正社員数",null,null,null,"非正社員数"]
[null,null,"-　　　　　　　-",null,null,null,null,null,null,null,null,null,"-　　　　　　　-",null,null,null,null,null,null,null,null,null,"□有り　　□無し",null,null,null,null,null,null,null,"人",null,null,null,"人"]
[null,null,"業　   　   種",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"直近の決算における年商"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　　　年　　　月決算　　　　　　　　　　　　　　　　万円"]
[null,null,"資　本　金",null,null,null,null,null,"資本金の25％以上を保有する大株主の氏名又は商号と出資比率"]
[null,null,"万円",null,null,null,null,null,"株主名",null,null,null,null,null,null,null,null,null,"出資\n比率",null,null,null,"％","株主名",null,null,null,null,null,null,null,null,null,"出資\n比率",null,null,null,"％"]
[null,null,null,null,null,null,null,null,"株主名",null,null,null,null,null,null,null,null,null,"出資\n比率",null,null,null,"％","株主名",null,null,null,null,null,null,null,null,null,"出資\n比率",null,null,null,"％"]
[null,null,"主要販売先（売上高順）","①",null,null,null,null,null,null,null,null,null,null,null,"□現金　□手形　　　　　％",null,null,null,null,null,null,null,"主要仕入先（取引高順）","①"]
[null,null,null,"②",null,null,null,null,null,null,null,null,null,null,null,"□現金　□手形　　　　　％",null,null,null,null,null,null,null,null,"②"]
[null,null,null,"③",null,null,null,null,null,null,null,null,null,null,null,"□現金　□手形　　　　　％",null,null,null,null,null,null,null,null,"③"]
[null,null,null,"④",null,null,null,null,null,null,null,null,null,null,null,"□現金　□手形　　　　　％",null,null,null,null,null,null,null,null,"④"]
[null,null,null,"⑤",null,null,null,null,null,null,null,null,null,null,null,"□現金　□手形　　　　　％",null,null,null,null,null,null,null,null,"⑤"]
[null,null,null,"⑥",null,null,null,null,null,null,null,null,null,null,null,"□現金　□手形　　　　　％",null,null,null,null,null,null,null,null,"⑥"]
[null,null,null,"⑦",null,null,null,null,null,null,null,null,null,null,null,"□現金　□手形　　　　　％",null,null,null,null,null,null,null,null,"⑦"]
[null,null,"２.代表者様及び担当者様についてについてご記入ください。"]
[null,null,"フリガナ",null,null,null,null,null,null,null,null,null,null,null,null,"　代表者の現住所　　　　　　□自己所有  □親族所有　□賃　貸 "]
[null,null,"代表者氏名",null,null,null,null,null,null,null,null,null,null,null,null,"〒"]
[]
[null,null,"代表者の生年月日",null,null,null,null,null,null,null,null,null,"性別",null,null,"配偶者",null,null,null,"代表者の携帯電話番号",null,null,null,null,null,null,null,null,"代表者の自宅電話番号"]
[null,null,"　　　　　　　 　　　  年　　　   月  　　 　日",null,null,null,null,null,null,null,null,null,"□男",null,null,"□有",null,null,null,"-　　　　　　-　",null,null,null,null,null,null,null,null,"-　　　　　　　-"]
[null,null,null,null,null,null,null,null,null,null,null,null,"□女",null,null,"□無"]
[null,null,"ご担当者名",null,null,null,null,null,null,null,null,"担当者様の連絡先",null,null,null,null,null,null,null,"連絡用メールアドレス　□代表者　□担当者"]
[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,"３.申込人及び代表者様の所有する資産（不動産、有価証券など）についてについてご記入ください。"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"時価　　　　　　　万円"]
[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,"時価　　　　　　　万円"]
[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,"時価　　　　　　　万円"]
[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,"時価　　　　　　　万円"]
[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,"時価　　　　　　　万円"]
[]
[null,null,"４.申込人及び代表者様の借入状況についてについてご記入ください。"]
[null,null,"借　入　先　名",null,null,null,null,null,null,null,null,null,"主たる債務者様",null,null,null,null,null,"担 保 差 入 状 況",null,null,null,null,null,null,null,null,null,null,null,null,"借入金残高"]
[null,null,null,null,null,null,null,null,null,null,null,null,"□法人　□個人",null,null,null,null,null,"□無担保　□有担保→（　　　　　　　　）",null,null,null,null,null,null,null,null,null,null,null,null,"万円"]
[null,null,null,null,null,null,null,null,null,null,null,null,"□法人　□個人",null,null,null,null,null,"□無担保　□有担保→（　　　　　　　　）",null,null,null,null,null,null,null,null,null,null,null,null,"万円"]
[null,null,null,null,null,null,null,null,null,null,null,null,"□法人　□個人",null,null,null,null,null,"□無担保　□有担保→（　　　　　　　　）",null,null,null,null,null,null,null,null,null,null,null,null,"万円"]
[null,null,null,null,null,null,null,null,null,null,null,null,"□法人　□個人",null,null,null,null,null,"□無担保　□有担保→（　　　　　　　　）",null,null,null,null,null,null,null,null,null,null,null,null,"万円"]
[null,null,null,null,null,null,null,null,null,null,null,null,"□法人　□個人",null,null,null,null,null,"□無担保　□有担保→（　　　　　　　　）",null,null,null,null,null,null,null,null,null,null,null,null,"万円"]
[]
[null,null,"※ご注意：お申込みには本書面と「融資申込書」を同時にＦＡＸにて返送していただく必要が有ります。"]
[null,null,null,null,null,null,null,null,null,null,null,null,"告　知　書　兼　同　意　書　　　　",null,null,null,null,null,null,null,null,null,null,null,null,null,"申込FAX番号048-682-2302"]
[]
[null,null,"５.申込人及び代表者個人又は代表者の家族について該当する項目に✔マークを記してください。（過去10年以内のみ）"]
[null,null,"自己破産を申し立てた事はありますか？",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"□無　□有　→　平成(　　　)年頃　□法人　□個人　□家族"]
[null,null,"債務整理を申し立てた事はありますか？",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"□無　□有　→　平成(　　　)年頃　□法人　□個人　□家族"]
[null,null,"発行した手形、小切手を不渡りとした事はありますか？",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"□無　□有　→　平成(　　　)年頃　□法人　□個人　□家族"]
[null,null,"法的整理（民事再生など）を申し立てた事はありますか？",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"□無　□有　→　平成(　　　)年頃　□法人　□個人　□家族"]
[]
[null,null,"６.よろしければアンケートにお答えください。（任意です）"]
[null,null,"　貸金業者を検索する際に、どのような検索エンジンをお使いになりましたか？　　　　□Yahoo　□Google　□その他"]
[null,null,"　貸金業者を検索する際に、どのような「キーワード」をお使いになりましたか？　（複数回答可）　　　"]
[]
[null,null,"法人と個人情報の取扱いに関する同意書"]
[null,null,"本申込に係る法人情報等の提供、登録、使用に関する同意内容は以下のとおりです。"]
[null,null,"１．【法人情報等及び個人情報の使用】"]
[null,null,"当社は、当社が加盟する信用情報機関（以下、「加盟先機関」という。）及び加盟先機関と提携する信用情報機関（以下、「提携先機関」という。）に申込者に係る法人貸付情報又は個人情報及び保証人予定者の個人情報が登録されている場合には、当該情報の提供を受け、返済又は支払能力を調査する目的のみに使用します。"]
[null,null,"２．【申込情報の信用情報機関への提供】"]
[null,null,"当社は、申込人及び保証人予定者に係る本申込に基づく個人情報（本人を特定する情報（氏名、生年月日、電話番号及び運転免許証等の記号番号等）、並びに申込日及び申込商品種別等の情報。以下、「申込情報」という。）を、加盟先機関に提供します。"]
[null,null,"３．【申込情報の登録】"]
[null,null,"加盟先機関は、当該申込情報を申込日から６ヶ月を超えない期間登録します。"]
[null,null,"４．【申込情報の他会員への提供】"]
[null,null,"加盟先機関は、当該申込情報を、加盟会員及び提携先機関の加盟会員に提供します。加盟先機関及び提携先機関の加盟会員は、当該申込情報を、返済又は支払能力を調査する目的のみに使用します。"]
[null,null,"５．【当社が加盟する信用情報機関及び当該機関が提携する信用情報機関】"]
[null,null,"当社が加盟する信用情報機関及び当該機関が提携する信用情報機関の名称及び連絡先は以下の通りです。"]
[null,null,"（当社が加盟する信用情報機関）"]
[null,null,"株式会社日本信用情報機構 TEL 0120-441-481 http://www.jicc.co.jp/"]
[null,null,"（当社が加盟する信用情報機関が提携する信用情報機関）"]
[null,null,"全国銀行個人信用情報センター TEL 03-3214-5020 http://www.zenginkyo.or.jp/pcic/"]
[null,null,"株式会社シー・アイ・シー TEL 0120-810-414 http://www.cic.co.jp/"]
[]
[]
[null,null,null,"株式会社髙島屋クレイキャピタル御中"]
[null,null,null,"上記の項目について、同意します。"]
[null,null,null,"同意者の署名",null,null,null,null,null,"商　　　　号"]
[null,null,null,null,null,null,null,null,null,"代表者の氏名"]
[null,null,"※署名欄に署名が無い場合にはお申込みいただけませんので、ご注意下さい。"]
[]
[null,null,null,"開示等の手続きについて"]
[null,null,null,"申込者及び保証人予定者は、加盟先機関に登録されている法人情報等に係る開示請求又は当該情報に誤りがある場合の訂正、削除等の申立を、加盟先機関が定める手続き及び方法によって行うことができます。"]