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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
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询问记录
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询问人：___________签名（盖章）
被询问人：_________签名（盖章）
记录人：___________签名（盖章）
