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["　　　　　　　　",null,null,null,null,null,"取材申込日",null,"　　　　年　   月   　日"]
["報道社名（局名）",null,null,null,null,null,"担当者名"]
[]
["連絡先","電話：　　　　　　　　　　　　　　　　　　　　　　内線（　　　　　）"]
[null,"e-mail： "]
["取材希望日時","年　　月　　日（　）",null,null,null,"  　　　時 　　　分",null,"～","  　　　時 　　　分"]
[]
["取　材　場　所"]
[]
["放送予定日時","年　　月　　日（　）",null,null,null,"  　　　時 　　　分",null,"～","  　　　時 　　　分"]
[]
["放 送 番 組 名","　　　　　　　　　　　　　　　　　　　　　　　　　　　生出演・生中継・録画"]
[]
["新聞等掲載予定日","年　　月　　日（　）",null,null,null,"朝刊・夕刊"]
[]
["出演・執筆者"]
[]
["\n取材内容\n（具体的に）"]