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# LSJE, LLC

6100 Red Hook Quarters, Suite B-3, St. Thomas, VI 00802-1348

Phone

E-mail: thesaintjames.group@gmail.com

## Emergency Contact Form

Today's Date: 4/9/19
Start Date: 4/5/19
Employee Name: CHARLES DICK
Date of Birth: <empty>
Physical Address: ST. THOMAS USVI 00802
Mailing Address: ST. THOMAS 00802
Cell Phone: <empty>
Phone (other): <empty>
E-mail: <empty>
Marital Status: Single
Title/Position: <empty>
Driver's License No: <empty>

Allergies or Health Concerns: N/A

Blood type:
[ ] A-
[ ] A+
[ ] AB-
[ ] AB+
[ ] B-
[ ] B+
[ ] O-
[ ] O+
[x] Unknown

Current Medications: N/A

Doctor's Name: N/A
Doctor's Phone: <empty>

Doctor's Name: <empty>
Doctor's Phone: <empty>

In case of emergency, please contact:
Name: <empty> Relationship: FRIEND Phone: <empty>
Name: <empty> Relationship: MOTHER Phone: <empty>

This information is for your safety and the safety ofothers.