) LSJE, LLC
| 6100 Red Hook Quarters Suite B-3 St. Thomas, VI 00802 LS ha LE

Fmergency Contact Form

Start Date: 03/22/18

Employee Name: Boniface Loud

Address: a Tham: Date of Birth: |

Marital Status: Married License: |
Ei mergency information
Allergies or Health Concerns; Blood type unspecified
Current Medication:
Doctor's Name: Dodglas Phone:
Doctor's Name: Dodglas Phone:

Mame ] | Relationship Wife Phone
ha re a Relationship In Law Phone

This Information is for your safety and the safety of others

EFTA00003043
