# LSJE, LLC

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

Phone:

E-mail: thesaintjames.group@gmail.com

## I mergency Contact Form

Today's Date: 01/11/18
Start Date: <empty>
Employee Name: Sylvester Gaillard
Date of Birth: <empty>
Physical Address: <empty> St Thomas, VI
Mailing Address: <empty> St Thomas, VI
Cell Phone: <empty>
Phone (other): <empty>
E-mail: <empty>
Marital Status: Single
Title/Position: Supervisor
Driver's License No: <empty>
Allergies or Health Concerns: None

Blood type:
[ ] Unknown

Current Medications: Diabetic Medications

Doctor's Name: Dr. Alah
Doctor's Phone: <empty>

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

## In case of emergency, please contact:

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

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

This information is for your safety and the safety ofothers