LSJE, LLC Wuarters, Suite B-3, St. Thomas, VI 00802-1 348 6100 Red Hook ¢ Phone E-mail: thesaintjames.group@gmail.com Emergency Contact Form Date 01/11/18 Start Date: | Employee Name \Sylvester Gaillard Date of Birth | | a St Thomas, Vi Physical Addre Mailing Addres i Cell Phone | tid Phone (other): E-maii | Marital Status: {Single Title/Position Supervisor Driver's License No: po ul None Allergies or Health Concerns: ‘ Blood type abet! Medics $ Current Medications: [P'#etic Mecicatior Doctor's Name: Dr. Alah Doctor's Phone Doctor's Name Doctor's Phone In case of emergency, please contact Name Relationship: | | Phone: This information is for your safety and the safety of others. EFTA00003070