申请人：      ，性别：        ，出生年月：           ，身份证（其他有效证件）号码：              ，工作单位：              ，住址（联系地址）：               ，邮政编码：     ，电话：        。

委托代理人：        ，电话：                    。

被申请人：                    。

行政复议请求：                                                                                

事实和理由：申请人于    年 月  日通过           的                                                               方式得知该具体行政行为，特申请行政复议，主要事实和理由：                                                   

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              。

此致

大石桥市人民政府

附件：1.行政复议申请书副本   份

      2.申请人身份证明材料复印件

      3.其他有关材料   份

      4.授权委托书（有委托代理人的）

                    申请人（签名或盖章）：         

                     年  月  日