共 页
询问时间________年______月______日_______时
询问地点____________________________________________________________
询问人_________________________记录人_______________________________
被询问人_________________________性别_______年龄____________________
政治面貌_________________________文化程度____________民族___________
单位及职务__________________________________________________________
住址及电话__________________________________________________________
询问主要内容________________________________________________________
询问记录____________________________________________________________
询问人签名(盖章)
被询问人签名(盖章)
记录人签名(盖章)
被询问人签名(盖章)
记录人签名(盖章)
