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LSJE, LLC
340-775-8108
Thomas, VI 00802 Tel: 340-775-8100 Fax:
It 6100 Red Hook Quarters Suite B-3 St.
Tat 3
Emergency Contact Form
Start Date:
Date: 04/11/12
Employee Name: Randy Amparo
Address: Date of Birth:
Phone: Cell: E-Mail:
Title / Position: Boat Captain Marital Status: Single License:
l mergency 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 Santo Amparo Relationship Father Phone
_,Name Reyna Amparo Relationship Mother Phone
This Information is for your safety and the safety of others