编号：_____________
申请人（初审机构）：_______________________________________
申请（经办）事项：_________________________________________
接收地点：_________________________________________________
接收时间：_________________________________________________
接收材料目录：_____________________________________________
1．________________________________________________________
2．________________________________________________________
3．________________________________________________________
4．________________________________________________________
申请人（初审机构经办人）：_________________________________
接收人：___________________________________________________
联系人：___________________________________________________
联系电话：_________________________________________________
监督电话：_________________________________________________
（行政许可实施机关行政许可专用章）：_________
_______________年____________月____________日
