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行政调解申请书

访问量:

申请人:

自然人姓名:           ;性别:      ;年龄:       

工作单位:                                           

住    址:                                           

联系电话:                                           

法人或其他组织名称:                                 

法定代表人:               ;职务:                  

住    所:                                           

联系电话:                                           

被申请人:

自然人姓名:           ;性别:      ;年龄:        

工作单位:                                           

住    址:                                           

联系电话:                                           

法人或其他组织名称:                                 

法定代表人:                ;职务:                 

住    所:                                           

联系电话:                                           

 

行政调解请求:                                       

                                                         

                                                        

                                                        

                                                        

                                                        

                                                        

                                                         

事实和理由:                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

 

特申请赣州市生态环境局予以调解。

 

申请人(签字):