LSJE, LLC
00802 Tel: 340-775-8100 Fax: 340-775-8108
6100 Red Hook Quarters Suite B-3 St. Thomas, VI
3
Emergency Contact Form
Start Date:
Date: 03/16/18
Employee Name: Justina de la Cruz
Address: Date of Birth:
Phone: Cell: E-Mail:
Title / Position: Housekeeper Marital Status: Married License:
ergency Information:
NA
Allergies or Health Concerns:
Blood Type:
Current Medication:
Doctor's Name: Phone:
Doctor's Name: Phone:
In case of an Emergency, Please contact :
Name Feliz de la Cruz Relationship Husband Phone
lame Bembenido Gedeno Relationship Brother Phone
This Information is for your safety and the safety of others
of •
I
EFTA01304181