EFTA01342060
LSJE, LLC
Phone:
Emergency Contact Form
Today's Date: 09/25/18 Start Date:
1
10/01/18
Employee Name: Keshaun Williams Date of Birth:
Physical Address:
Mailing Address:
Cell Phone: Phone (other):
E-mail: Marital Status:
Title/Position: Engineer Driver's License No:
Allergies or Health Concerns: N/A
Blood type:
A- 7 A+ E AB- E AB+ B+ ❑X O+ ❑ Unknown
Current Medications:
Doctor's Name: Doctor's Phone:
Doctor's Name:
Doctor's Phone:
1
In case of emergency, please contact:
Name: Burnet Williams Relationship: Mom Phone:
Name: Jess James Relationship: Friend Phone:
This information is for your safety and the safety
of others.