# LSJE, LLC

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

Fax:

# Emergency Contact Form

Date: 04/11/12
Start Date: <empty>

Employee Name: Randy Amparo
Address: <empty>
Date of Birth: <empty>

Phone: <empty>
Cell: <empty>
E-Mail: <empty>

Title / Position: Boat Captain
Marital Status: Single
License: <empty>

## mergency Information:

Allergies or Health Concerns: NA

Blood Type: <empty>

Current Medication: <empty>

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

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

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

Name: <empty>
Relationship: Mother
Phone: <empty>

This Information is for your safety and the safety ofothers