} LSJE, LLC B-3 St. Thomas, V1 00802 Tel: 340-775-8100 Fax: 340-775-8108 6100 Red Hook Quarters Suite ad - = Emergency Contact Form Date: 06/04/18 Start Date: Employee Name: Dann wi 8 §€6C Date of Birth: — ——_—$ ition: Me Marital Status: Single License: Rte Emergency Information Allergies or Health Concerns: Current Medication: 4 Doctor's Name: Dodglas Phone: Doctor's Name: Dodglas Phone: In case of an Emergency, Please contact : Phone - A me Po Relationship —_ Girlfriend Phone Name Maria Relationship Etienne This Information is for your safety and the safety of others EFTA00003049