EFTA01304178.pdf

EFTA01304178 C P p C I LSJE, LLC Tel: 340-775-8100 Fax: 340-775-8108 6100 Red Hook Quarters Suite B-3 St. Thomas, VI 00802 Emergency Contact Form Date: 03/19/18 Start Date: Employee Name: Hilian Bedminster Address: 9107 Est Thomas SNQ14D Date of Birth: 04/07/78 Phone: 340-642-5999 Cell: E-Mail: Title / Position: Paint Marital Status: Single License: [0000035968 mergency Informa?' Allergies or Health Concerns: Blood Type: O- Current Medication: Doctor's Name: Phone: Doctor's Name: Phone: In case of an Emergency, Please contact : Name Mariana Bedminster Relationship Mother Phone 340-642-7994 ame Ann Relationship Anty Phone 340-514-1350 This Information is for your safety and the safety of others