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调解申请书
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）：__________________________________________________
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_______________________________________________________________________________纠纷事实及申请事项：_______________________________________________________
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特申请________________________________________人民调解委员会予以调解。
申请人（签名）_______________________登记日期________年________月________日
