EFTA00003045.pdf

LSJE, LLC 
6100 Red Hook Quarters. Suite B-3. St. Thomas. VI 00802-1348 
Phone: 
E-mail: thesaintjames.group@gmail.com 
Emergency Contact Form 
Today's Date: 
Employee Name: 
Physical Address' 
10/15/18 
}Carlos L Rodriguez 
Start Date: 
Date of Birth: 
Thomas. VI 06802 
ro. Red Hook 
a 
Mailing Address. 
Cell Phone: 
E-mail: 
U 
Title/Position: 
Faotain 
Phone (other): 
Marital Status: 
Driver's License No: I.= 
lamed 
Allergies or Health Concerns: L 
Blood type: 
El A- 
D A+ 
D AB- 
C AB+ 
El g- 
EJ 8+ 
o- 
D o+ 
QX Unknown 
Current Medications: r ime
Doctors Name: 
Doctors Name: 
Livingston 
Doctors Phone: 
Doctor's Phone: 
In case of emergency, please contact: 
Name: 
Name: 
Relationship: 
Relationship: 
Phone: 
Phone: 
This information is for your safety and the safety of others. 
EFTA00003045

Size: 61 x 9 pixels

Surrounding text: 100 Red Hook Quarters, Si hone: E-n

Size: 41 x 20 pixels

Surrounding text: Birth:

Size: 76 x 13 pixels

Surrounding text: Name: Carlos L Rodriguez St Thon dress: 6501 Red Hook Plaza

Size: 62 x 14 pixels

Size: 96 x 17 pixels

Surrounding text: - on: Captain

Size: 56 x 14 pixels

Surrounding text: Married No:

Size: 71 x 17 pixels

Size: 80 x 17 pixels

Surrounding text: case of emergency, please contact: Name: Name:

Size: 66 x 25 pixels