# 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: 1-16-2019
Start Date: 3-25-2019
Employee Name: Maurice Bedminster
Date of Birth: <empty>
Physical Address: <empty> St. Thomas U.S. V.I
Mailing Address: <empty> St. Thomas U.S. V.I 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: <empty> [ ] Unknown

Current Medications: N/A

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

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