EFTA00003064

L LSJE, LLC 6100 Red Hook Quarters Suite B-3 St. Thomas, VI 00802 Tel: 3 Date: 03 19:8 Employee Name: Pd rick L. Cena Address: Phone Title / Position: Captain i mergency Information: Allergies or Health Concerns: Blood Type: Current Medication: Doctor's Name: Doctor's Name: Emergency Contact Form Fax Start Date: 02t05/18 S.€ x 1 s vi 00802 Date of Birth: Cell: No blood type spectfied In case of an Emergency, Please contact : Name ante E-Mail: Marital Status: Divorce License: Relationship Phone: Phone: Father/Stepmother Phone Relationship Fnend Phone This Information is for your safety and the safety of others EFTA00003064