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