询问笔录(治安案件)

第   次

时间_____年_____月_____日_____时_____分_____至_____年_____月_____日_____时_____分

地点_____________________________________________________________

询问人_________________________   工作单位_____________________

记录人_________________________   工作单位_______________________

被询问人_______________ 性别__________   

出生日期_______________文化程度_______________

户籍所在地________________________________________

现住址____________________________________________

工作单位__________________________________________

联系电话__________________________________________

问：我们是_______________________的工作人员，现依法向你询问____________________案的有关问题，请你如实回答。对于本案无关的问题，你有拒绝回答的权利。你听清楚没有？ 

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