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[null,null,"工　事　実　績　証　明　書"]
[]
[{"$nulls":7},"　"]
[]
[null,"　　（発注者）　　　　　　　様"]
[]
[{"$nulls":6},"受注者"]
[{"$nulls":6},"住所"]
[{"$nulls":6},"商号又は名称"]
[{"$nulls":6},"代表者氏名","　　　　　　　　　　　　　　　　　　　　,"]
[{"$nulls":5},"　"]
[]
[null,"　　　次の工事を履行したことを証明願います。"]
[null,"　"]
[null,"　","事　業\n年　度","工　事　名","工 事 概 要","施 工 場 所","契約金額","工　　期","契　約","完　成","履行状況"]
[null,"　",{"$nulls":6},"年月日","年月日"]
[]
[null,"　"]
[]
[null,"　"]
[]
[]
[]
[]
[]
[null,"　"]
[null,"　"]
[null,"　"]
[null,"　"]
[null,"　"]
[null,"　"]
[]
[]
[null,null,"上記工事を履行したことを証明します。"]
[null,null,"　  　　年　　月　　日"]
[{"$nulls":7},"発注者（証明者）",null,null,"　　　,"]
[]
[]
[null,"注１　この様式は、類似工事施工実績を証明するために使用すること。　"]
[null,"　２　この様式は、申請者が共同企業体の場合は各構成員ごとに作成すること。"]
[null,"　３　「契約金額」欄は、受注実績が共同企業体の構成員としてのものである場合は、当該共同企業体としての"]
[null,"　　請負金額のほか構成員としての出資割合を記載すること。"]
[]
[{"$nulls":8},"（用紙寸法　日本工業規格Ａ４）"]