EFTA01342067

LSJE, LLC 6100 Red Hook Quarters Suite B-3 St. Thomas, VI 00802 Tel: Date: 03/25/18 Employee Name: Pierre Jules Emergency Contact Form Fax: Start Date: Address: Date of Birth: Phone: Cell: E-Mail: n/a Title / Position: Operator Marital Status: Single License: i mergency Information: Allergies or Health Concern Blood Type: Current Medication: Doctor's Name: n a Phone: n a Doctor's Name: n/a Phone: n a In case of an Emergency, Please contact : Relationship Brother Phone Relationship Friend Phone This Information is for your safety and the safety of others EFTA01342067