申请人：______________
法定代表人：______________ 
委托代理人：______________ 
被申请人：________________                                                                                                    
               请求事项
________________________________________________________
              事实和理由
_____________________________________________ 
    
    此致

_____________海事法院
                                                                 
                                                                 申请人： 
                                                                 年 月 日