} LSJE, LLC 6100 Red Hook Quarters Suite B-3 St. Thomas, VI 00802 ri Emergency Contact Form Date: 04/11/12 Start Date Employee Name: Randy Amparo Address: Fp Date of Birth: re Phone Cell: E-Mail: Po ———— Title / Position: Boat Captain Marital Status: Single License: | Eee nergency Information: Allergies or Health Concerns: “s Blood Type: pe ort Current Medication: Doctor's Name: Phone: Doctor's Name: Phone: in case of an Emergency, Please contact: Name | Relationship Father Phone i PF Relationship Mother Phone This Information is for your safety and the safety of others EFTA00003067