Employee Emergency Contact Form - Carlos L. Rodriguez, LSJE LLC

EMERGENCY CONTACT FORM

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

FORM DETAILS: Today's Date: 10/15/18 Start Date: [BLANK] Employee Name: Carlos L. Rodriguez Date of Birth: [REDACTED] Physical Address: [REDACTED], St. Thomas, VI 00802 Mailing Address: 6501 Red Hook Plaza Cell Phone: [REDACTED] Phone (other): [BLANK] E-mail: [REDACTED] Marital Status: Married Title/Position: Captain Driver's License No: [REDACTED]

MEDICAL INFORMATION: Allergies or Health Concerns: [BLANK] Blood Type: Unknown Current Medications: None Doctor's Name: Dr. Livingston Doctor's Phone: [REDACTED] Doctor's Name (2nd): [BLANK] Doctor's Phone (2nd): [BLANK]

EMERGENCY CONTACTS: Primary Contact Name: [REDACTED] Relationship: Wife Phone: [REDACTED] Secondary Contact Name: [BLANK] Relationship: [BLANK] Phone: [BLANK]

Note: Multiple fields are redacted or blank. The form footer states: 'This information is for your safety and the safety of others.'

Names mentioned: - Carlos L. Rodriguez — Employee; held position of Captain at LSJE LLC as of October 2018 - Dr. Livingston — Listed physician/medical doctor