CENTRO DE CONCILIACIÓN

“GALOVI”
AUTORIZADO SU FUNCIONAMIENTO POR
R.D. N° 063-2013-JUS/DGDP-DCMA.

EXP. N°________________________

SOLICITUD PARA CONCILIAR

I. DATOS GENERALES:
1. Fecha_______________________________________________________________________
2. Nombre o razón social del (los) solicitante (s) _______________________________________
____________________________________________________________________________
3. Documento de identidad o RUC del (los) solicitante(s)________________________________
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4. Domicilio del (los) solicitante(s )__________________________________________________
____________________________________________________________________________
5. Nombre del apoderado o representante ___________________________________________
6. Domicilio del apoderado o representante___________________________________________
7. Nombre o razón social del (los) invitado(s)__________________________________________
____________________________________________________________________________
8. Domicilio(s) del (los) invitado (s) _________________________________________________
____________________________________________________________________________

II. HECHOS QUE DIERON LUGAR AL CONFLICTO:

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III. OTRAS PERSONAS CON DERECHO ALIMENTARIO:

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CENTRO DE CONCILIACIÓN GALOVI
Av. Tullumayo N°856-B - Cusco
+51 84 236994
 CENTRO DE CONCILIACIÓN

“GALOVI”
AUTORIZADO SU FUNCIONAMIENTO POR
R.D. N° 063-2013-JUS/DGDP-DCMA.

IV. PRETENSIÓN.

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________________________________________________________________________________
________________________________________________________________________________
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V. FIRMA DEL SOLICITANTE O HUELLA DIGITAL SEGÚN EL CASO:

____________________________
Nombre y documento de Identidad

VI. DOCUMENTOS QUE ADJUNTO:

1. ___________________________________________________________________________
2. ___________________________________________________________________________
___________________________________________________________________________
3. ___________________________________________________________________________
___________________________________________________________________________

CENTRO DE CONCILIACIÓN GALOVI

Av. Tullumayo N°856-B - Cusco
+51 84 236994