询问地点：____________________________________________
    询问时间：____年____月____日____时____分至____时____分
    询问机关：____________________________________________
    询问人：______________________________________________
    记录人：______________________________________________
    被询问人姓名：______  性别：____ 年龄：_____ 民族：___
　　文化程度：_______   职业：_____ 工作单位：____________
　　住址：________________________________________________

    问：____________________________________________________________________________________________________________
    答：____________________________________________________________________________________________________________