时间_____年_____月_____日_____时_____分_____至_____年_____月_____日_____时_____分
地点_________________________________________________________________
询问人_________________________工作单位___________________________
记录人_________________________工作单位___________________________
被询问人_______________性别__________
出生日期_______________文化程度_______________
户籍所在地________________________________________
现住址____________________________________________
工作单位__________________________________________
联系电话__________________________________________
问:我们是_______________________的工作人员,现依法向你询问____________________案的有关问题,请你如实回答。对于本案无关的问题,你有拒绝回答的权利。你听清楚没有?
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