申请人：_________________姓名_______________年龄_______________性别__________住址___________

申请人：_________________姓名_______________年龄_______________性别__________住址________________

________________.(法人或者其他组织名称_____________

________________住址________________

_____________法定代表人或者主要负责人姓名_________________)

委托代理人：_________________姓名_______________住址________________.

被申请人：_________________名称________________住址________________

_______________.

行政复议请求：________________

_______________.

事实和理由：_____________

_______________.

此致

_____________(行政复议机关)

申请人：__________________

__________________年__________________月__________________日