信访事项登记表
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信访事项登记表
姓名:__________________
性别:__________________
年龄:__________________
联系电话:__________________
所属单位/住址:_______________
信访事项简述:
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
事项发生时间:______________________
事项发生地点:______________________
事项涉及人员:______________________
详细描述: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
证据材料清单:
1._______________________
2._______________________
3._______________________
4._______________________
5._______________________
目标:(请简要描述您希望通过此次信访事项解决的问题)
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
期望解决方案:(请陈述您对此事项的期望解决方案)
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
备注:(如有需要,请在此处添加任何其他相关信息)
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
我承诺以上提供的信息属实,并愿意配合有关部门进行调查。
签名:______________________
日期:______________________