申訴人:____________________________
委托代理人:________________________
被訴人:____________________________
委托代理人:________________________
申訴事由及請求的情況:
____________________________________________________________________________________
____________________________________________________________________________________
調解達成協議的內容:
____________________________________________________________________________________
____________________________________________________________________________________
申訴人:________________
被訴人:________________
仲裁員:________________
______勞動爭議仲裁委員會
______年______月______日
xx市xx區人民法院