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調解申請表

Mediation Application Form
 
I. 爭議方Parties in the Dispute 
 
 
申請人Applicant
公司名稱Company Name:
 
法人代表Company Representation:
                                          電話Telephone  :
聯系人Contact Person:
 
聯系地址Address:
  
郵編Postal Code:
 
城市,國家City, Country:
 
電話Telephone:         
 
傳真Fax:
 
電子郵件E-Mail:
 
代理人Representation
                                          電話Telephone
聯系地址Address
                                          傳真Fax
電子郵件E-Mai
                             
 
 
 
被申請人Respondent
公司名稱Company Name  :
 
法人代表Cormpany Representation:
                                          電話Telephone:  
聯系人Contact Person:
 
聯系地址Address:
 
郵編Postal Code:
 
城市,國家City, Country:
 
電話Telephone:         
 
傳真Fax:
 
電子郵件E-Mail:
 
代理人Representation
                                          電話Telephone
聯系地址Address
                                          傳真Fax
電子郵件E-Mail
                             
 
 
 
II.爭議內容 Nature of the Dispute  
基本事實The basic facts
爭議要點Controversial points
調解請求Mediation request
  
 
爭議雙方在將爭議提交調解時,須隨此申請表格附送陳述材料(各一式四份)用以說明基本事實、爭議要點和調解請求。雙方還應盡可能提交賠償說明或可能解決爭議的方案。
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.  規則和程序 Rules and Procedures  
 
爭議雙方同意遵守現行有效的中國國際貿易促進委員會調解中心調解規則。調解須由調解中心按其規定執行。
如果爭議雙方同意修改該規則修改的規則須包括在申請表中。
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. 爭議金額 Value of the Claim
 
 預計爭議金額
Estimated value of the claim:
 
 
V.  免于責任和補償 Hold Harmless and Indemnity
 
爭議各方同意,如果調解員因忠實履行職責而導致任何一方當事人可能承擔一定的損失、費用或損害,則各方保證該調解員不會因此受到任何損害。
爭議雙方同意補償調解員在忠實履行職責時所承擔的任何損失、費用或損害。
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.
 
 
將此表填完后請郵寄或傳真至RETURN COMPLETED FORM BY FAX OR MAIL TO:
中國貿促會/中國國際商會調解中心
CCPIT/CCOIC Mediation Center
 聯系方式Contact Information
 
中國北京西城區樺皮廠胡同2號國際商會大廈四層   郵編:100035
CCOIC Building, 2 Huapichang Hutong, Xicheng District, Beijing100035,China
電話Tel: (86-10) 82217081
傳真Fax: (86-10) 82217099
電子郵件E-mail: flwangfang@ccpit.org
 
網址Website:oggtours.com
 
 
申請人Applicant                                          被申請人Respondent                              
    
 簽字Sign                                                   簽字Sign:                               
 
 蓋章Seal                                                    蓋章Seal:                           
                                                    
 日期Date                                                           日期Date: