委托人(自益受益人):________________
法定代表人:__________________________
营业执照号:__________________________
营业地址或住址:______________________
联系地址:____________________________
邮政编码:____________________________
联系电话:____________________________
传真:________________________________
受托人:______________________________
法定代表人:__________________________
住所地:______________________________
邮政编码:____________________________
联系电话:____________________________
传真:________________________________
他益受益人:__________________________
性别:__________________