EFTA01304183
I
LSJE, LLC
6100 Red Hook Quarters Suite B-3 St. Thomas, VI 00802 Tel: 340-775-8100 Fax: 340-775-8108
Emergency Contact Form
Date: 04/09/18 Start Date:
Employee Name: Onel Pierresaint
Address: Date of Birth:
Phone: Cell: E-Mail:
Title / Position: Marital Status: Married License:
I nergency Information:
Blood type unspecified
Allergies or Health Concerns:
Blood Type:
Current Medication:
Doctor's Name:
Phone:
Doctor's Name:
Phone:
In case of an Emergency, Please con
tact :
Name Rose Marie Jean Baptiste Relationship Wife
Phone
S ame Robenio Joseph Relationship Friend Phone
This Information is for your safe
ty and the safety of others