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: 10/15/18 Start Date:
Employee Name: }Carlos L Rodriguez Date of Birth:
Physical Address' Thomas. VI 06802
Mailing Address. ro. Red Hook a
Cell Phone: Phone (other):
E-mail: U Marital Status: lamed
Title/Position: Faotain Driver's License No: I.=
Allergies or Health Concerns:
L
Blood type:
El A- D A+ D AB- C AB+ El g- EJ 8+ o- D o+ QX Unknown
Current Medications: r ime
Doctors Name: Livingston Doctors Phone:
Doctors Name:
Doctor's Phone:
In case of emergency, please contact:
Name: Relationship: Phone:
Name: Relationship: Phone:
This information is for your safety and the safety
of others.
EFTA00003045