（首页）　　　　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）