EFTA01342063
LS E LLC
Emergency Contact Form
Date: 04/09/18 Start Date:
Employee Name: Onel Pierresaint
Address: Date of Birth:■
Phone: E -Mail:
Title / Position: Marital Status: Married License: L
I nergency Information:
Blood type unspecified
Allergies or Health Concerns:
Losartan Potassium 50 mg Tab
Doctor's Name: Rosal Joselito Phone:
Doctor's Name:
Phone:
In case of an Emergency, Please contact
:
Name Rose Marie Jean Baptiste Relationship Wife
Phone
glI3 me Robenio Joseph Relationship Friend Phone
This Information is for your safety
and the safety of others