# LSJE, LLC

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

Phone:

E-mail: thesaintjames.group@gmail.com

## Emergency Contact Form

| Field                   | Value              |
|-------------------------|--------------------|
| Today's Date            | 10/17/18           |
| Employee Name           | Brian Bates        |
| Title/Position          | Contractor         |
| Marital Status          | Single             |
| Blood Type              | Unknown            |
| Current Medications    | None               |
| Doctor's Name           | Jamie Reed         |
| 1st Emergency Contact Relationship | Girlfriend     |
| 2nd Doctor's Name       | None               |


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