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：____________________________________________________________________________________________________________
