V
LSJE, LLC
00 Red Hook Quarters Suite B-3 St. Thomas, VI 00802 Tel: Fax:
Emergency Contact Form
Date: C6'4'18 Start Date: 04/20/18
Employee Name: Michae J G,caen
Address: rSJ Date of Birth:
Phonc. Cell: E-Mail:
Title / Position: Engineer Marital Status: Divorce License:
3 ergency Information:
Allergies or Health Concerns:
Blood Type:
Current Medication:
Doctor's Name: Phone:
Doctor's Name:
Phone:
In case of an Emergency, Please contact:
Maine Relationship Son Phone
Relationship Brother Phone
This Information is for your sofety and the safety
of others
EFTA00003061