# LSJE, LLC

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

Phone:

E-mail: thesaintjames.group@gmail.com E-mail: thesaintjames.group@gmail.com

## Emergency Contact Form

Today's Date: 10/21/18
Start Date: <empty>
Employee Name: Peter St Omer
Date of Birth: <empty>
Physical Address: <empty>
Mailing Address: <empty> St Thomas, VI 00802
Cell Phone: <empty>
Phone (other): <empty>
E-mail: <empty>
Marital Status: Married
Title/Position: Operator
Driver's License No: <empty>
Allergies or Health Concerns: N/A

Blood type:

[ ] Unknown

Current Medications: <empty>

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

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

In case of emergency, please contact:
Name: Kishma
Relationship: Friend
Phone: <empty>

Name: Demitri
Relationship: Son
Phone: <empty>

This information is for your safety and the safety of others.