EFTA00003058.pdf

LSJE, LLC 
6100 Red Hook Quarters Suite B-3 St. Thomas. VI 00802 Tel: 340-775-8100 Fax: 340-775-8108 
Date: 
03/16/1B 
Employee Name: Justina de Is Cruz 
Emergency Contact Form 
Start Date: 
Address: 
Date of Birth: 
Phone: 
Cad 
E-Mail: 
Title / Position: Housekeeper 
Marital Status: Marred 
License: 
nergency Information: 
v. 
Allergies or Health Concerns: 
Blood Type: 
Current Medication: 
Doctor's Name: 
Doctor's Name: 
In case of an Emergency, Please contact: 
Name 
Feliz de la Cruz 
eaame 
Bembenido Gedeno 
Relationship 
Phone: 
Phone: 
Husband 
Phone 
Relationship 
Brother 
Phone 
This Information is for your safety and the safety of others 
EFTA00003058

Size: 56 x 17 pixels

Surrounding text: Name: Justina de la Cru

Size: 38 x 14 pixels

Surrounding text: Birth:

Size: 63 x 14 pixels

Surrounding text: Cell:

Size: 49 x 24 pixels

Surrounding text: or Health Concerns: Type: Medication:

Size: 64 x 48 pixels

Surrounding text: hers