时间：______年_____月_____日_____时_____分至____时_____分
地点：___________________________________________________
侦察员姓名：_______________ 单位：______________________
记录员：___________________ 单位：______________________
被询问人……（姓名、性别、出生年月日、民族、出生地、文化程度等。）
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
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