_________________________   _________________________

居住 / 注册地址        居住 / 注册地址

_________________________   _________________________

_________________________   _________________________

_________________________   _________________________

邮政编码            邮政编码

_________________________   _________________________

联系电话            联系电话

_________________________   _________________________

委托代理人           经纪人员

_________________________   _________________________

                资格证编号：

                _________________________

               ____年___月___日签于：上海