LSJE, LLC 6100 Red Hook Quarters Suite B-3 St. Thomas, V1 00802 Tel; 340-775-8100 Fax: 340-775-8108 Emergency Contact Form Date: 03/16/18 Start Date: Employee Name: Justina de la Cruz Address: Po Date of Birth: | Phone: ce E-Mail: Title / Position: Housekeeper Marital Status: Married License: rgency Information: NA Allergies or Health Concerns: — a Current Medication: Doctor's Name: Phone: Doctor's Name: Phone: In case of an Emergency, Please contact : Name Feliz de la Cruz Relationship Husband Phone td - Same Bembenido Gedeno Relationship Brother Phone This Information is for your safety and the safety of others EFTA00003058