上诉人__________住所地______________________________________________________________
                  法定代表人（或代表人）姓名__________职务___________________电话_____________________
                  被上诉人________住所地______________________________________________________________
                  法定代表人（或代表人）姓名__________职务___________________电话_____________________
                  上诉人因_________________________________________________一案，不服_________人民法院

                  ____年__月__日（____）______字第____号_________________________________,现提出上诉。
                  上诉请求
                  ____________________________________________________________________________________
                  上诉理由
                  ____________________________________________________________________________________
                  此致

                  __________人民法院
                  附：本上诉状副本__份
                  上诉人________
                  ____年__月__日