EFTA01256961.pdf

EFTA01256961 LSJE, LLC 340-775-8100 Fax: 340-775-8108 6100 Red Hook Quarters Suite B-3 St. Thomas, VI 00802 Tell: 5 Emergency Contact Form Date: 03 25 8 Start Date: Employee Name: Pierre Jules Address: Date of Birth: Phone: 340-998-9893 Cell: E-Mail: n/a Title / Position: Operator Marital Status: Single License: I I mergency Information: nia Allergies or Health Concerns: Blood type unspecified Blood Type: Current Medication: Doctor's Name: n/a Phone: nia Doctor's Name: n/a Phone: n/a In case of an Emergency, Please contact : Name Bert Juies Relationship Brother Phone l ame Argentina Perez Relationship Friend Phone This Information is for your safety and the safety of others