# LSJE, LLC

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

Fax:

## Emergency Contact Form

Date: 03/25/18
Start Date: <empty>

Employee Name: Pierre Jules
Address: <empty>
Date of Birth: <empty>

Phone: <empty>
Cell: <empty>
E-Mail: n/a

Title / Position: Operator
Marital Status: Single
License: <empty>

## mergency Information:

Allergies or Health Concerns:
n/a
Blood type unspecified

Blood Type: <empty>

Current Medication:

Doctor's Name: n/a
Phone: n/a

Doctor's Name: n/a
Phone: n/a

In case of an Emergency, Please contact :
Name <empty> Relationship Brother Phone <empty>
Name <empty> Relationship Friend Phone <empty>

This Information is for your safety and the safety of others