EFTA01342068

sir _ Tor LSJE, LLC 6100 Red Hook Quarters Suite B-3 St. Thomas, VI 00802 Tel: 3 Date: 04/11/12 Employee Name: Randy Amparo Address: Phone: Cell: E-Mail: Title / Position: Boat Captain mergency Information: Allergies or Health Concerns: Blood Type: IO Current Medication: Doctor's Name: Doctor's Name: NA In case of an Emergency, Please contact : Name Jame Relationship Relationship Marital Status: Phone: Phone: Emergency Contact Form Fax: Start Date: Date of Birth: License: Father Phone Mother Phone This Information is for your safety and the safety of others EFTA01342068