行政复议申请书

（公民） 

申 请 人：      ，性别    ，    年    月   生，身份证号码：             ，住所（联系地址）                。

委托代理人：                     

被 申 请 人：                      

法定代表人：                

地址：                                               

委托代理人：                                          

行政复议请求：

                                                                                  

                                                                                         

事实和理由：                   

                                   

                                         

                                                                                                                                                                                                                                                                                                                                                                                       

    此致

中站区人民政府

                      

                     申请人:

                                     年   月   日

作者：区司法局