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["申报部门：                                                  省（区、市）科技厅（委、局）                                                  "]
["（盖章）                                                                                                                                                        填表日期：       年      月    日 "]
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["申报部门：          省（区、市）科技厅（委、局）                                                  "]
["（盖章）                                                                                                                                          填表日期：       年      月         日"]
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["申报部门：                                                  省（区、市）科技厅（委、局）                                                  "]
["（盖章）                                                                                                                                                        填表日期：       年      月    日 "]
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["申报部门：          省（区、市）科技厅（委、局）                                                  "]
["（盖章）                                                                                                                                          填表日期：       年      月         日"]
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