EFTA01304186
C
LSJE, LLC
6100 Red Hook Quarters, Suite B-3, St. Thomas, VI 00802-1348
Phon E-mail: thesaintjames.group@gmail.com
Emergency Contact Form
Today's Date: [10/21/18 Start Date:
Employee Name: Peter St Omer Date of Birth
Physical Address:
Mailing Address:
Cell Phone: Phone (other):
E-mail: Marital Status: Married
Title/Position: Operator Driver's License No:
Allergies or Health Concerns: N/A
Blood type:
A- El A+ E AB- El AB+ EJ B+ ❑ o- n o+ ri Unknown
Current Medications:
Doctor's Name:
Doctor's Phone:
Doctor's Name:
Doctor's Phone:
In case of emergency, please contact:
Name: Kishma
Relationship: Friend Phone:
Name: Demitri
Relationship: Son Phone:
This information is for your safety and the
safety of others.