当事人(自然人姓名,性别,年龄,民族,职业,单位或住址,法人及社会组织的名称,
地址,法定代表人姓名和职务):___________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
纠纷简要情况:_____________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
经调解,自愿达成如下协议:_________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
履行协议的方式,地点,期限:______________________________________________
_______________________________________________________________________________
本协议一式______份,当事人,人民调解委员会各持一份.
当事人(签名或盖章)____________________________
调解员(签名)__________________
x人民调解委员会
_________年________月_______日