申訴人：____________________________

委托代理人：________________________

被訴人：____________________________

委托代理人：________________________

申訴事由及請(qǐng)求的情況：

____________________________________________________________________________________

____________________________________________________________________________________

調(diào)解達(dá)成協(xié)議的內(nèi)容：

____________________________________________________________________________________

____________________________________________________________________________________

申訴人：________________

被訴人：________________

仲裁員：________________

______勞動(dòng)爭(zhēng)議仲裁委員會(huì)

______年______月______日

xx市xx區(qū)人民法院