LSJE, LLC

6100 Red Hook Quarters Suite B-3 St. Thomas, V1 00802 Tel: 340-775 £100 Fax: 340-775-8108

Emergency Contact Form

Dat 09/10/18 Start Date: 08/26/2018
ate: 11 — ab

Employee Name: Stephanie Remington

Address: I 1-3 Estote Smith Ray SiS Date of Birth: {| EEGEGzG

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Title / Position: Asst to Manager Marital Status: Single License: EE

ency Information:

Allergies or Health Concerns:

Blood Type: BB

Doctor's Name: [sland Health & Wellness Center nor J

Doctor's Name: Phone:

In case of an Emergency, Please contact :

«3 IE Relationship Son Phone

This Information is for your safety and the sa fety of others

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