EFTA01304187

It Tat O p T O CJ LSJE, LLC 6100 Red Hook Quarters Suite B-3 St. Thomas, VI 00802 Tel: 340-775-8100 Fax: 340-775-8108 3 Date: 04/11/12 Employee Name: Randy Amparo Address: Phone: Title / Position: Boat Captain l mergency Information: Allergies or Health Concerns: Blood Type: Current Medication: Doctor's Name: Doctor's Name: NA Emergency Contact Form Cell: In case of an Emergency, Please contact : Name Santo Amparo Relationship _,Name Reyna Amparo Relationship Start Date: Date of Birth: E-Mail: Marital Status: Single License: Father Mother Phone: Phone: Phone Phone This Information is for your safety and the safety of others EFTA01304187