Emergency Contact Form for Nicholas Victorin - LSJE, LLC

EMERGENCY CONTACT FORM

ORGANIZATION: LSJE, LLC Address: 6100 Red Hook Quarters, Suite B-3, St. Thomas, VI 00802-1348 Phone: [REDACTED] Email: thesaintjames.group@gmail.com

STATUS: Declined to Complete (handwritten notation on document)

EMPLOYEE INFORMATION: Employee Name: Nicholas Victorin Today's Date: [BLANK] Start Date: [BLANK] Date of Birth: [BLANK] Physical Address: [BLANK] Mailing Address: [BLANK] Cell Phone: [BLANK] Phone (other): [BLANK] E-mail: [BLANK] Marital Status: [BLANK] Title/Position: [BLANK] Driver's License No: [BLANK]

HEALTH INFORMATION: Allergies or Health Concerns: [BLANK] Blood type: [BLANK - checkboxes for A-, A+, AB-, AB+, B-, B+, O-, O+, Unknown] Current Medications: [BLANK]

DOCTOR INFORMATION: Doctor's Name: [BLANK] Doctor's Phone: [BLANK] Doctor's Name: [BLANK] Doctor's Phone: [BLANK]

EMERGENCY CONTACTS: Name: [BLANK] Relationship: [BLANK] Phone: [BLANK] Name: [BLANK] Relationship: [BLANK] Phone: [BLANK]

Footer: 'This information is for your safety and the safety of others.'

Names mentioned: - Nicholas Victorin — Employee for LSJE, LLC; subject of this emergency contact form who declined to complete it