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["报名点（盖章）：                                    填表人：                                   填表日期："]
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["备注：1.所附派出相关文件应包括有支援地、支援起止时间及派出人员名单等信息。2.申报临床、中医、口腔、公卫类主任或副主任医师资格的，需填写执业类别及执业范围。                                                                "]

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["报名点（盖章）：                                    填表人：                                   填表日期："]
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["备注：1.所附派出相关文件应包括有支援地、支援起止时间及派出人员名单等信息。2.申报临床、中医、口腔、公卫类主任或副主任医师资格的，需填写执业类别及执业范围。                                                                "]