当事人：_____________________________
    委托代理人：_________________________
    案件承办机关：_______________________
    案件承办人：_________________________
    听证员：_____________________________
    听证主持人：_________________________
    书记员：_____________________________
    听证方式：___________________________
    听证时间：___________________________
    听证地点：___________________________

    听证案由：_______________________________________________________________________________________________________

    案件基本情况：___________________________________________________________________________________________________

    当事人主要理由：_________________________________________________________________________________________________

    案件承办人主要理由：_____________________________________________________________________________________________

    听证合议意见：___________________________________________________________________________________________________

    负责人意见：_____________________________________________________________________________________________________

听证人员签名：__________
负责人签名：____________
______年______月______日