时间_____年_____月_____日_____时_____分_____至_____年_____月_____日_____时_____分
地点_________________________________________________________________
讯问人_________________________工作单位___________________________
记录人_________________________工作单位___________________________
被讯问人_______________曾用名__________性别__________
出生日期_______________文化程度_______________
户籍所在地________________________________________
现住址_____________________________________________
被讯问人身份证件名称及号码_____________________________________________
工作单位_______________________________________________________________
联系电话_______________________________________________________________
问:___________________________________________________________________
答_____________________________________________________________________
问:___________________________________________________________________
答:___________________________________________________________________