当事人:_____________________________
委托代理人:_________________________
案件承办机关:_______________________
案件承办人:_________________________
听证员:_____________________________
听证主持人:_________________________
书记员:_____________________________
听证方式:___________________________
听证时间:___________________________
听证地点:___________________________
听证案由:_________________________________________________________
案件基本情况:_____________________________________________________
当事人主要理由:___________________________________________________
案件承办人主要理由:_______________________________________________
听证合议意见:_____________________________________________________
负责人意见:_______________________________________________________
听证人员签名:__________
负责人签名:____________
______年______月______日