陈述申辩书

时间：     年    月    日    时    分至    日    时    分

地点：                                                               

陈述申辩人：           性别：      职务：           

电话：                 联系地址：            邮编：          

执法人员：              执法证号：                

                        执法证号：                

记录人：                  

陈述申辩记录:                                                          

                                                                      

                                                                      

                                                                     

                                                                     

                                                                     

                                                                      

                                                                     

                                                                     

                                                   

陈述申辩人签名及时间：                                                                                                              

执法人员签名：                       、                                                                                               

记录人签名：