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
