<p>申請人：__________________、性別____________、年齡____________、職業____________、住址____________、聯繫電話____________、身份證號碼____________。</p><p>被申請人：________________、性別____________、年齡____________、職業____________、住址____________、聯繫電話____________、身份證號碼____________。</p><p>申請人因不服被申請人_________________年_________________月_________________日作出的_________________具體行政行爲，向_________________機關提出複議申請，要求_________________。</p><p>事實及理由：</p><p>1.________________________________</p><p>2.________________________________</p><p>(受理複議申請的行政機關)</p><p>申請人：_________________(簽名或蓋章)</p><p>_____年_____月_____日<strong></strong></p>
