臨床修練許可証再交付申請書及び臨床修練証明書（様式第五号・第六号）
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39令和8年6月25日木曜日官報(号外第140号)
様式第五号(第八条第二項関係)
※許可番号
※再交付年月日
臨床修練許可証/臨床教授等許可証再交付申請書
APPLICATION FOR REISSUE OF CERTIFICAT
ATE OF PERMISSION OF ADVANCED CLINICAL TRAINING /
CLINICAL TEACHING AND RESEARCH
□臨床修練許可証
許可証の種別
Certification of
Type of Permission
□臨床教授等許可証
Permit No.
1,000可年月日 Permit
f Clinical teaching and research
月{
1,,0
Month
1,000
一国
Nationality, etc.
EE
PIACN of Biriblect
11
(原語)(in Original Letters)
(ロ-マ字)
(in Roman Letters)
(カタカナ)
(in Japanese Katakana)
14
19
Sex
100
、女{
Female
(Last)
(Last)
(First)
(First)
(Middle)
(Middle)
1
月{
生 ate of Birth
Year
Month
-0.00
上記の許可証を(破つた・汚した・失つた)000
で、関係書類を添えて許可証の再交付を申請します。
the
the necessary
documents.
| | | 88 | | 日本における居住地Present Address in Japan |
| HF年{100.014Date of Birth | Name | 14 | | 電話番号 Tel. No. | |
| | | (原語)(in Original Letters) | 電話番号 Tel. No. | 日本における居住地Present Address in Japan |
| HF年{100.014Date of Birth | (カタカナ)(in Japanese Katakana) | (in Romen(In Roman Lottors) | | 電話番号 Tel. No. | |
| (カタカナ)(in Japanese Katakana) | | 電話番号 Tel. No. | 日本における居住地Present Address in Japan |
| | (in Original Letters) | 電話番号 Tel. No. | |
| (in Japanese Katakana) | | (in Original Letters) | | |
| | | | |
| (in Japanese Katakana) | (In Roman Lottors) | (in Original Letters) | | |
| Year | (in Japanese Katakana) | | | | |
| (Last) | (Last) | | | |
| 月{Month | (First) | | | 11 | |
| 10.00 | | | | 10 | c/o |
| | (First) | | |
| (Middle) | | | | |
| | (Middle) | | | |
| | | | | 24 |
厚生労働大臣
To: Minister
2,
(Date)
1
Year
1,00019
Welfare
Month
10.00
署名
Signature
様式第六号(第十一条関係)
臨床修練証明書
CERTIFICATE OF ADVANCED CLINICAL TRAINING
国籍等 出生地
Nationality, etc. Place of Birth
氏名(原語)
(in Original Letters)
(Name)
(ローマ字)
(in Roman Letters) (Last) (First) (Middle)
生年月日 年 月 日
Date of Birth Year Month Day
上記の者は、次のとおり、臨床修練を行った者であることを証明する。
This is to certify that the person mentioned above received the advanced clinical training, as follo
1.臨床修練を行った病院の名称
Name of hospital in which he/she has received advanced clinical training
2.臨床修練の内容
Details of advanced clinical training
3.臨床修練の期間
Term of advanced clinical training
+F1 月 日
(Date) Year Month Day
President of Hospital Hospital Hospital Hospital Hospital and
臨床修練指導医(指導歯科医・指導者)印
Clinical Instructor
上記の者は、外国医師等が行う臨床修練等に係る医師法第17条等の特例等に関する法律第3
条第1項の規定に基づき、臨床修練の許可を受けた者であることを証明する。
This is to certify that under the provision of Article 3, Paragraph 1 of the Law concerning the
Exceptional Cases of the Medical Practitioners Act, Article17, on the Advanced Clinical Training of
Foreign Medical Practitioners, etc., the person mentioned above was granted permission for advanced
clinical training.
年月日
Year Month Day
厚生労働大臣
Minister of Health, Labour and Welfare
ST