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:______________________