LSJE, LLC
6100 Red Hook Quarters Suite B-3 5t. Thomas, VI 00802 Tel: [EE a

Emergency Contact Form

Date: 04/09/18 Start Date:

Employee Name: Onel Pierresaint

Address: Date of Birth:

Phone: ne Cell: E-Mail:

Title / Position: Marital Status: Married

cod
License: 2 |

snl nero ency Information:

Blood type unspecified
Allergles or Health Concerns:

Doctor's Name: Rosal Josslilo

Blood Type:

Current Medication:

Doctor's Name:

In case of an Emergency, Please contact :

Mame
Phone
= ime 3 :

Relationship Wife

This Information is for your safety and the safety of others

EFTA00003062
