) LSJE, LLC

#100 Red Hook Quarters, Suite B-3, St. Thomas, VI 00802-1 348
— - Phone: he F-mail: thesaintjames.group/@ gmail.com

| Emergency Contact Form

| Today's Date: 9125/18 Start Date: [1001/1 : |
| be : TT TACT
Employee Name: Keshaun Willams Date of Birth: a 3 | f
Physical Address: | |
Mailing Address:
Cell Phone: Phone (other): | |
E-mail: Marital Status: |
Title/Position: [Engineer Driver's License No: _}
Allergies or Health Concerns: - |
Blood type;
[] Unknown
Current Medications: | |
Doctor's Name: : 3 Doctor's Phone: -
Doctor's Name 3 Doctor's Phone: | h
—
In case of emergency, please contact: |

noe: | | Relationship: Morn 3 Phone:
Name DE Relationship: [Friend - Phone:

C This information is for your safety and the safety of others.

EFTA00003059
