劳仲案字[ ]第 号
申诉人:____________________________
委托代理人:________________________
被诉人:____________________________
委托代理人:________________________
申诉事由及请求的情况:
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调解达成协议的内容:
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申诉人:________________
被诉人:________________
仲裁员:________________
______劳动争议仲裁委员会
______年______月______日
附:1.本调解书一式三份,由双方当事人及仲裁委员会各存一份。
2.本调解书自送达之日起具有法律效力。