EFTA00003063

LSJE, LLC 6100 Red Hook Quarters Suite B-3 St. Thomas, VI 00802 Tel: 340-775-8100 Fax: 340-775-8108 Date: 03/19/18 Employee Name: Oriole Joseph Address: Phon Title/ Position: Maintenance limergency Information: Allergies or Health Concerns: Blood Type: Current Medication: Doctor's Name: Doctor's Name: Emergency Contact Form Blood type unspecified Start Date: 10/01/16 Date of Birth E-Mail: Marital Status: Single License: Phone: Phone: In case of an Emergency, Please contact : Relationship Phone Relationship Cousin Phone This Information is for your safety and the safety of others EFTA00003063