调解申请表
调 解 申 请 表
Mediation Application Form
I. 争议方Parties in the Dispute
申请人Applicant
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公司名称Company Name:
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法人代表Company Representation:
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电话Telephone :
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联系人Contact Person:
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联系地址Address:
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邮编Postal Code:
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城市,国家City, Country:
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电话Telephone:
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传真Fax:
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电子邮件E-Mail:
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代理人Representation：
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电话Telephone：
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联系地址Address：
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传真Fax：
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电子邮件E-Mai：
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被申请人Respondent
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公司名称Company Name :
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法人代表Cormpany Representation:
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电话Telephone:
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联系人Contact Person:
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联系地址Address:
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邮编Postal Code:
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城市,国家City, Country:
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电话Telephone:
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传真Fax:
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电子邮件E-Mail:
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代理人Representation：
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电话Telephone：
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联系地址Address：
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传真Fax：
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电子邮件E-Mail：
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II.争议内容Nature of the Dispute
基本事实The basic facts
争议要点Controversial points
调解请求Mediation request
争议双方在将争议提交调解时，须随此申请表格附送陈述材料（各一式四份）用以说明基本事实、争议要点和调解请求。双方还应尽可能提交赔偿说明或可能解决争议的方案。
The parties shall attach a description（in quadruplicate.）of the nature, circumstances and matters of the dispute giving rise to the claims and which are being submitted for mediation. If possible, both parties should also submit statements of remedies or possible solutions sought.
III. 规则和程序Rules and Procedures
争议双方同意遵守现行有效的中国国际贸易促进委员会调解中心调解规则。调解须由调解中心按其规定执行。
如果争议双方同意修改该规则, 修改的规则须包括在申请表中。
The parties agree to be bound by the Rules and Procedures of Mediation Center of China Council for the Promotion of International Trade, as amended from time to time. The Mediation shall be administered by the Mediation Center pursuant to its Rules
If the parties agree to modify the Rules, the modifications shall be included with the application form.
IV. 争议金额Value of the Claim
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预计争议金额
Estimated value of the claim:
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V. 免于责任和补偿Hold Harmless and Indemnity
争议各方同意，如果调解员因忠实履行职责而导致任何一方当事人可能承担一定的损失、费用或损害，则各方保证该调解员不会因此受到任何损害。
争议双方同意补偿调解员在忠实履行职责时所承担的任何损失、费用或损害。
The parties agree to hold the mediator(s) harmless for any loss, costs or damage that may result to either parties from the mediator's good faith performance of their duties. They parties agree to indemnify the mediators for any loss, costs, or damage they may bear as a result of carrying out in good faith, their duties as mediators.
申请人Applicant 被申请人Respondent
签字Sign： 签字Sign：
盖章Seal： 盖章Seal
日期Date： 日期Date
