┏━━━┯━━━━━━┯━━━━━━┯━━━┯━━━━━━┯━━━━━┓
┃  申  │  名    称  │            │  被  │  名    称  │          ┃     
┃  诉  ├──────┼──────┤  诉  ├──────┼─────┨
┃  方  │  地    址  │            │  方  │  地    址  │          ┃      
┠───┼──────┼──────┼───┼──────┼─────┨
┃  代  │  姓    名  │            │  代  │  姓    名  │          ┃      
┃  表  ├──────┼──────┤  表  ├──────┼─────┨
┃  人  │  职    务  │            │  人  │  职    务  │          ┃      
┠───┴──────┼──────┼───┴──────┼─────┨
┃  合同名称、编号    │            │      签订日期      │          ┃      
┠──────────┼──────┼──────────┼─────┨
┃  鉴  证  编  号    │            │      鉴证机关      │          ┃      
┠──────────┼──────┴──────────┴─────┨
┃    是否经过调解    │                                              ┃ 
┠──────────┴───────────────────────┨
┃纠纷的原因及其经过：                                                ┃       
┃                                                                    ┃ 
┠──────────────────────────────────┨
┃申诉的理由和要求：                                                  ┃
┃                                                                    ┃
┠──────────────────────────────────┨
┃证据、证人姓名和住址：                      原诉方：    （盖章）    ┃
┃                                                                    ┃       
┃                                                年    月    日      ┃
┠────┬────────────┬────┬───────────┨
┃仲裁机关│                        │仲裁机关│                      ┃
┃收到申请│                        │对受理此│          （盖章）    ┃
┃时间、收│                        │案的意见│                      ┃   
┃到人    │                        │        │      年    月    日  ┃
┗━━━━┷━━━━━━━━━━━━┷━━━━━━━━━━━━━━━━┛



　　颁布单位：国家工商管理局
　　颁布日期：１９８６