（此处印制公安机关名称）
检查笔录
检查时间_____年_____月_____日_____时_____分_____至_____年_____月_____日_____时_____分
检查人______________ 工作单位_____________________________________________
检查证文号___________________________________________________________________
检查对象____________________________________________________________________________
检查过程及情况______________________________________________________________________
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检查人：__________ 记录人：__________
当事人或者见证人（签名 ）： _______________