行政复议申请书
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