EFTA00003058

LSJE, LLC 6100 Red Hook Quarters Suite B-3 St. Thomas. VI 00802 Tel: 340-775-8100 Fax: 340-775-8108 Date: 03/16/1B Employee Name: Justina de Is Cruz Emergency Contact Form Start Date: Address: Date of Birth: Phone: Cad E-Mail: Title / Position: Housekeeper Marital Status: Marred License: nergency Information: v. Allergies or Health Concerns: Blood Type: Current Medication: Doctor's Name: Doctor's Name: In case of an Emergency, Please contact: Name Feliz de la Cruz eaame Bembenido Gedeno Relationship Phone: Phone: Husband Phone Relationship Brother Phone This Information is for your safety and the safety of others EFTA00003058