EFTA Document EFTA01304169

LSJE, LLC 6100 Red Hook Quarters Suite B-3 St. Thomas, VI 00802 Tel: Emergency Contact Form Date: 03/22/18 Employee Name: Bonitace Loudat Address: Bo vont 16-3G iv'TPI. St Thomas mergency Information: None Allergies or Health Concerns: Blood type unspecified Current Medication: Doctor's Name: Dodglas Doctor's Name: Dodglas In case of an Emergency, Please contact : Name Nell Leudat I Start Date: 03/22/18 Date of Birth: E-Mail: Marital Status: Married License: I_ Phone: Phone: Relationship Wife Phone Relationship In Law Phone This Information is for your safety and the safety of others EFTA01304169