Employee Emergency Contact Form for Maintenance Staff Member

EMERGENCY CONTACT FORM

Company: LSJE, LLC Address: 6100 Red Hook Quarters Suite B-3, St. Thomas, VI 00802 Telephone: 340-775-8100 Fax: 340-775-8108

Form Date: 03/19/18 Employee Start Date: 10/01/16

Employee Name: Oriole Joseph Address: [REDACTED] Date of Birth: [REDACTED]

Phone: [REDACTED] Cell: [REDACTED] E-Mail: [REDACTED]

Title/Position: Maintenance Marital Status: Single License: [blank]

Emergency Information: Allergies or Health Concerns: [blank] Blood Type: Unspecified Current Medication: [blank]

Doctor's Name: [blank] | Phone: [blank] Doctor's Name: [blank] | Phone: [blank]

In Case of Emergency, Please Contact: Name: [REDACTED] | Relationship: Cousin | Phone: [REDACTED] Name: [REDACTED] | Relationship: Cousin | Phone: [REDACTED]

Statement: 'This Information is for your safety and the safety of others'

Names mentioned: - Oriole Joseph — Employee in maintenance position at LSJE, LLC; started October 1, 2016