EFTA01342063.pdf

EFTA01342063 LS E LLC Emergency Contact Form Date: 04/09/18 Start Date: Employee Name: Onel Pierresaint Address: Date of Birth:■ Phone: E -Mail: Title / Position: Marital Status: Married License: L I nergency Information: Blood type unspecified Allergies or Health Concerns: Losartan Potassium 50 mg Tab Doctor's Name: Rosal Joselito Phone: Doctor's Name: Phone: In case of an Emergency, Please contact : Name Rose Marie Jean Baptiste Relationship Wife Phone glI3 me Robenio Joseph Relationship Friend Phone This Information is for your safety and the safety of others