EFTA Document EFTA01342059

LSJE, LLC 6100 Red Hook Quarters Suite B-3 St. Thomas, VI 00802 Tel: 340-775-8100 Fax: 340-775-8108 Date: 03/16/18 Employee Name: Justine de la Cruz Emergency Contact Form Start Date: Address: Date of Birth: Phone: Cell: E-Mail: Title / Position: Housekeeper Marital Status: Married License: t tergency Information: Allergies or Health Concerns: Blood Type: ■ Current Medication: Doctor's Name: Doctor's Name: NA In case of an Emergency, Please contact : Name Feliz de la Cruz - 'lame Bembenido Gedeno Phone: Phone: Relationship Husband Phone Relationship Brother Phone This Information is for your safety and the safety of others EFTA01342059