# 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: 09/25/18
Start Date: 10/01/18
Employee Name: Keshawn Williams
Date of Birth: <empty>
Physical Address: <empty>
Mailing Address: <empty>
Cell Phone: <empty>
Phone (other): <empty>
E-mail: <empty>
Marital Status: <empty>
Title/Position: Engineer
Driver's License No: <empty>
Allergies or Health Concerns: N/A

Blood type:
<empty> [ ] 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: <empty>
Relationship: Mom
Phone: <empty>

Name: <empty>
Relationship: Friend
Phone: <empty>

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

Thisinformation isfor your safety and the safety of others