中国国际商会调解中心以调解的方式，解决发生在商事、海事等领域的争议。包括当事人在贸易、投资、知识产权、房地产、物流、金融证券、保险等领域争议的调解。
调解中心受理下列争议案件：
（一） 国际的或涉外的争议案件；
（二） 涉及香港特别行政区、澳门特别行政区和台湾地区的争议案件；
（三） 国内争议案件

注*
调解员认为确有必要到外地察看调查的，调解人员的食宿、交通费用等实际开支，按合理的费用标准向当事人收取。
如调解程序因故中止，调解中心可根据调解工作的进展情况和实际开支，适当返还当事人预交的部分调解费。

 

 

 

I. 争议方PARTIES IN THE DISPUTE 
申请人Applicant
公司名称Company Name:
法人代表Company Representation:                      电话Telephone  :

联系人Contact Person: 
联系地址Address: 

邮编Postal Code:                                     城市,国家City, Country: 
电话Telephone:                                       传真Fax: 
电子邮件E-Mail: 

代理人Representation：                               电话Telephone：

联系地址Address：                                    传真Fax：

电子邮件E-Mai：                              

被申请人Respondent

公司名称Company Name  : 
法人代表Cormpany Representation:                     电话Telephone:  
联系人Contact Person: 
联系地址Address: 
邮编Postal Code:                                     城市,国家City, Country: 
电话Telephone:                                       传真Fax: 
电子邮件E-Mail: 
代理人Representation：                               电话Telephone：
联系地址Address：                                    传真Fax：
电子邮件E-Mail：                              

 

II.争议内容NATURE OF THE DISPUTE  
基本事实The basic facts
争议要点Controversial points
调解请求Mediation request
  

争议双方在将争议提交调解时，须随此申请表格附送陈述材料（各一式四份）用以说明基本事实、争议要点和调解请求。双方还应尽可能提交赔偿说明或可能解决争议的方案。
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.  规则和程序RULES AND PROCEDURES
争议双方同意遵守现行有效的中国国际贸易促进委员会调解中心调解规则。 调解须由调解中心按其规定执行。
如果争议双方同意修改该规则, 修改的规则须包括在申请表中。
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. 争议金额VALUE OF THE CLAIM

预计争议金额
Estimated value of the claim: 

V.  免于责任和补偿HOLD HARMLESS AND INDEMNITY

争议各方同意，如果调解员因忠实履行职责而导致任何一方当事人可能承担一定的损失、费用或损害，则各方保证该调解员不会因此受到任何损害。争议双方同意补偿调解员在忠实履行职责时所承担的任何损失、费用或损害。
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.

将此表填完后, 请邮寄或传真至RETURN COMPLETED FORM BY FAX OR MAIL TO:
中国贸促会/中国国际商会调解中心扬州办事处CCPIT/CCOIC Mediation Center yangzhou branch
 

联系方式 Contact Information
扬州市文昌中路18号国贸大厦1楼    邮编：225009
电        话Tel: 0514-87855682 / 87859352
传        真Fax: 0514-87891464
电子邮件E-mail:ccpitzq@126.com
网       址www.yzccpit.org

申请人Applicant                                  被申请人Respondent
    
 签字Sign：                                      签字Sign：

 盖章Seal：                                      盖章Seal：
                                                    
 日期Date：                                      日期Date：