甲方：_____________________
乙方：_____________________
甲乙双方就__________纠纷事宜，经_________律师事务所的律师主持调解，双方协商一致达成如下协议：_______
________________________________________________________________________________________________________
甲方：________________
乙方：________________
调解人：______________
律师__________________
签约日期：____________