EFTA01304185

A § 41 LSJE, LLC 6100 Red Hook Quarters Suite B-3 St. Thomas, VI 00802 Tel: 340-775-8100 Fax: 340-775-8108 3 Date: 03/19/18 Employee Name: Patrick L. Cena Address: Phone: Title / Position: Captain Amergency Information: Allergies or Health Concerns: Blood Type: Current Medication: Doctor's Name: Doctor's Name: Emergency Contact Form Cel No blood type specified In case of an Emergency, Please contact : Name Pat & Emily Cena Relationship n ame Stephanie Remington Relationship Start Date: 02/05/18 Date of Birth E-Mail: Marital Status: Divorce License: I Phone: Phone: Father/Stepmother Friend Phone Phone This Information is for your safety and the safety of others EFTA01304185