<p>申请人：__________________、性别____________、年龄____________、职业____________、住址____________、联系电话____________、身份证号码____________。</p><p>被申请人：________________、性别____________、年龄____________、职业____________、住址____________、联系电话____________、身份证号码____________。</p><p>申请人因不服被申请人_________________年_________________月_________________日作出的_________________具体行政行为，向_________________机关提出复议申请，要求_________________。</p><p>事实及理由：</p><p>1.________________________________</p><p>2.________________________________</p><p>(受理复议申请的行政机关)</p><p>申请人：_________________(签名或盖章)</p><p>_____年_____月_____日<strong></strong></p>