劳仲案字[ ]第 号
申诉人：________________________
委托代理人：____________________
被诉人：________________________
委托代理人：____________________
申诉理由、争议事实和要求：
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裁决结果：
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_________________________________________________________________________________________
费用负担：
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不服裁决，向人民法院起诉的期限：
_________________________________________________________________________________________
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首席仲裁员：____________
仲裁员：________________
仲裁员：________________
______劳动争议仲裁委员会
______年______月______日