LSJE, LLC
6100 Red Hook Quarters, Suite B-3, St. Thomas, VI 00802-1348
Phone: E-mail: thesaintjames.group@gmail.com
a
Emergency Contact Form
Today's Date: 10/17/18 Start Date:
Employee Name: Brian Bates Date of Birth:
rater on Boat - AYH
Physical Address:
Mailing Address: I
Cell Phony Phone (other):
E-mail. Marital Status: Single
Title/Position: Contractor Driver's License No:
Allergies or Health Concerns:
Blood type: If
Current Medications: None ih
Doctor's Name: Jamie Reed
Doctor's Phone:
Doctor's Name: None
Doctor's Phone:
In case of emergency, please contact:
Name: Laurie McLeod Relationship: Girlfriend Phone:
Name: Relationship: Phone:
This information is for your safety and the safety of
others.
EFTA01304170