元氏县人民政府
 
发布时间:2020-12-19    来源:司法局
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 询 问 笔 录

                                                                                      

  由:                                                      

时间:                     分至      分。

地点:                                            

被调查(询问)人:             性别:     年龄:      身份证号码:              

工作单位:                             职务:           电话:          

  址:                                      邮编:                      

调查(询问)人及执法证编号:                            记录人:              

问:我们是元氏县医疗保障局的执法人员(出示工作证件),现依法向你询问,你应当如实回答,对与案件无关的问题,你有拒绝回答的权利,你有要求执法人员或者执法机关负责人回避的权利,有陈述和申辩的权利,以上权利义务,你清楚了吗?       

答:                                                                   

问:你的个人情况?                                                                       

答:(姓名、性别、年龄、身份证号、工作单位、职务、电话、住址)                                                                                        

问:(相关案情)                                                                                  

答:                                                                                    

                                                                                                          

                                                                                       

  (以下是调查(询问)笔录尾页)                                                                                             

应注明调查(询问)笔录上述内容,记录属实。”                                              

被调查(询问)人签字:                                                                    

调查(询问)人签字:                                                      

记录人签字:                                                            

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