EFTA01304173.pdf

EFTA01304173 LSJE, LLC 6100 Red Hook Quarters, Suite B-3, St. Thomas. VI 00802-1348 Phone: 340-775-2525 E-mail: thesaintjames.groupriegmail.com Emergency Contact Form Today's Date: 10/18/18 Start Date: Employee Name: 'Donald Poilon Date of Birth: Physical Address: I Mailing Address: Cell Phone Phone (other): E-mail: Marital Status: Title/Position: Driver's License No: Allergies or Health Concerns: I Blood type: A- EJ A+ E AB- E AB+ B+ 70- r- Unknown Current Medications: Doctor's Name: Doctor's Phone: Doctor's Name: Doctor's Phone: In case of emergency, please contact: Name: Relationship: Phone: Name: Relationship: Phone: This information is for your safety and the safety of others.