LSJE, LLC
6100 • 1 sok uarters, Suite B-3, St. Thomas. VI 00802-1348
Phone: E-mail: thesaintjames.group@gmail.com
Emergency Contact Form
Today's Date: 110/17/18 Start Date:
Employee Name: Brian Bates Date of Birth:
Physic3! Address:
Mailing Address:
Cell Plior Phone (other):
E-mail. Marital Status: Single
Title/Position: IGOntrader Driver's License No:
Allergies or Health Concerns:
IM
Blood type:
El A- O A+ lE AB- El AB+ El 8- lit O O. El O+ Unknown
Current Medications: h ne
Doctors Name: Jamie Reed
Doctors Phone:
Doctor's Name: None
Doctor's Phone:
In case of emergency, please contact:
Name: Relationship: Girlfriend Phone:
Name: Relationship:
Phone:
This information is for your safety and
the safety of others.
EFTA00003044