询 问 笔 录

时间：      年  月  日  时   分至  时   分           第    次询问

地点：                                                               

询问人：                                   记录人：                  

被询问人：                         与案件关系：                     

性别：             年龄：                      

身份证号：                               联系电话：                  

工作单位及职务：                                                    

联系地址：                                                          

问：我们是                                                         的执法人员                    ，这是我们的执法证件，执法证件号码分别是               、               ，请你确认。现依法向你询问，请如实回答所问问题。执法人员与你有直接利害关系的，你可以申请回避。你是否申请回避？

答：                                                                

问：                                                                

                                                                    

答：                                                                

                                                                    

                                                                    

                                                                    

                                                                    

    被询问人签名：                                  第   页 共    页

                                                                    

                                                                    

                                                                    

                                                                    

                                                                    

                                                                    

                                                                    

                                                                    

                                                                    

                                                                    

                                                                    

                                                                    

                                                                    

                                                                    

                                                                    

                                                                    

                                                                    

                                                                    

                                                                    

                                                                    

                                                                    

 

被询问人签名及时间：               询问人签名及时间：

                                           

                                        

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