injury tort claims where the Company is a "non-subscriber" and is not a covered employer under the state's workers' compensation
insurance program.
F. If any of the foregoing terms of the Agreement are determined to be in violation of any law, rule or regulation or
are otherwise unenforceable, that determination shall not affect any other clauses of the Agreement. All other clauses shall remain in full
force and effect. If any EDSI Rules or Procedure is determined by any court of competent jurisdiction to be invalid or unenforceable,
EDSI shall be permitted a reasonable period of time to amend its Rules and Procedures in order to accomplish the arbitration purpose of
this Agreement.
G. My Agreement shall continue for the period of my employment with the Company unless mutually terminated in
writing by EDSI and me. However, I acknowledge that if this Agreement is terminated, any claim that arose prior to the termination of
the Agreement shall be covered by this Agreement and must be submitted to arbitration in the EDSI forum.
H. My Agreement supersedes any and all prior understandings and agreements between the parties, or with the
Company, concerning the resolution of any and all claims or disputes between the Company, its supervisors, managers, and/or other
agents, and me. It contains the entire understanding and agreement of the parties regarding these subjects. My agreement may not be
altered or amended, except in writing signed by the President of EDSI and me.
I. The agreement is effective immediately. I understand I have the right to consult with an attorney of my choice
prior to executing this Agreement.
J. I have read the Agreement carefully and have been given a copy of the EDSI Rules and Procedures. I knowingly
and voluntarily agree to be bound by the terms and conditions of the Agreement and the EDSI Rules and Procedures, as modified and/or
amended from time to time, except that should the EDSI Rules and Procedures be modified or amended. I shall have the right to choose
to have my employment-related dispute resolved under the Rules and Procedures that are in effect on the date I sign this Agreement or
the Rules and Procedures in effect on the date I file a claim with EDSI.
__________________________
________________________________
Date
Name (Please Print)
________________________________
Address
________________________________
City, State, Zip
________________________________
Social Security Number
__________________________
________________________________
Witness
SIGNATURE
This Agreement must be signed by a parent or guardian of the applicant if the applicant is less that 18 years of age on the date
this Agreement is signed.
________________________________
PARENT OR GUARDIAN
_________________________ ________________________________
Date
Name (Please Print)
________________________________
Address
________________________________
City, State, Zip
________________________________
Social Security Number
*This agreement must be notarized if not witnessed by an Agent of the Company.
Please indicate whether you wish to be considered for purposes of serving as an "Adjudicator" or arbitrator and participating in hearings
and deciding disputes under the EDSI Rules and Procedures.
YES_______ NO_______
Note: Your indication of interest is no assurance that you will be selected for Adjudicator training or to serve as an Adjudicator.
Employment Dispute Services, Inc. P O Box 30326 Charleston, South Carolina 29417-0326
Inquiries may be directed to EDSI's Toll Free Number: 800-892-5335
C:Word/EDSI/EdsiForm/Appagree/Rev.6-2000
