EFTA Document EFTA01304188

• e. "ff 8, t • • .0• LSJE, LLC 6100 Red Hook Quarters Suite B-3 St. Thomas, VI 00802 Tel: 340-775-8100 Fax: 340-775-8108 Date: 04/09/18 Employee Name: Emergency Contact Form Start Date: Address: Date of Birth: 06/20/67 Phone: Cell: I E-Mail: Title / Position: Housekeeper Marital Status: Married License: [ /Emergency Information: Allergies or Health Concerns: Blood Type: Current Medication: Doctor's Name: Doctor's Name: No Phone: Phone: In case of an Emergency, Please contact : Name 'Jame Relationship Relationship Pastor Phone Phone This Information is for your safety and the safety of others • • • - r • 4. ..• • t • is •"'" •, D , • • • • %• • trt •• • • ••• to • • • • • • .• ti • • • • SONY GM 00169398 0 • • $ is EFTA01304188