价格争议调解处理申请书
申请人（甲）：          性别：    年龄：          
民族：               职业：                         
单位:                                      
住址:                                           
邮编：           电话:                       
传真：          电子邮箱：                  
法人代表：             职务：                 
住址：                    电话：              
委托代理人:          住址:                  
电话：                 
申请人（乙）：          性别：    年龄：         
民族：               职业：                        
单位:                                     
住址:                                          
邮编：           电话:                      
传真：          电子邮箱：                  
法人代表：             职务：                  
住址：                    电话：              
委托代理人:          住址:                  
电话：                
价格争议事项:                                    
价格争议事实、请求及理由 （可另附页）:                  
                                                                                    
                                                                                                                                   
                                                                                                                                   
                                                                                                                                   
                                                                                                                                                      
申请人提供的相关证据和材料：
申请人（甲）：                                 
                                                                                                
申请人（乙）：                                    
                                                                                                     
其他需要说明的有关事项（可另附页）：                             
                                                                 
                                                                 
特申请                    对上述价格争议予以调解处理。
声明：1、该争议事项未经过其他价格争议调解处理机构调解。
      2、该争议事项未经提起诉讼、行政复议等其他法律程序。
 
申请人（甲）签名（盖章）：   
 
申请人（乙）签名（盖章）:               
 
 
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