人民调解口头协议登记表

编号：______________

当事人姓名____________性别_______民族________年龄_________ 职位或职务________________________联系方式____________________ 单位或地址____________________________________________________

当事人姓名___________性别________民族________年龄_________ 职位或职务________________________联系方式____________________ 单位或地址____________________________________________________

纠纷主要事实、争议事项：__________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

经调解，自愿达成如下协议：________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________

履行方式、时限： ___________________________

人民调解员（签名）__________________________

（人民调解委员会印章）

_____年_____月_____日

备注：此表由人民调解委员会填写