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[]
[]
["受影响职工个人申请表"]
["姓名",null,null,"性别",null,"年龄"]
["身份证号码",{"$nulls":3},"学历"]
["家庭地址",{"$nulls":3},"手机号码"]
["原所在企业"]
["解除劳动合同时间",null,null,"解除劳动合同原因","    □合同到期    □主动离职 "]
[{"$nulls":4},"    □企业裁员    □其他"]
["目前是否就业","□是   □否",null,"是否符合失业保险金领取条件",{"$nulls":3},"□是   □否"]
["是否生活困难","□是 □否","生活困难类型"," □城乡低保家庭  □建档立卡贫困户家庭"]
[{"$nulls":3}," □特困供养人员  □困难(特困)职工"]
["真实性声明"]
["     本表所填内容不含任何虚假成份，否则，本人愿意承担由此产生的一切"]
[" 责任。"]
["     特此声明。"]
[]
["                                             签字："]
["                                                         年   月   日"]
["审核意见"]
["        经核，符合/不符合“受影响职工”条件。"]
[]
[]
["                                        人力资源社会保障部门（盖章）"]
["                                                       年    月    日"]

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