Employee Emergency Contact Form for Peter St Orner, LSJE LLC

EMERGENCY CONTACT FORM

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

Form Date: 10/21/18 Employee Name: Peter St Orner Start Date: [BLANK] Date of Birth: [REDACTED]

Physical Address: [REDACTED] Mailing Address: [REDACTED], St Thomas, VI 00802

Cell Phone: [REDACTED] Phone (other): [BLANK] E-mail: [BLANK] Marital Status: Married

Title/Position: Operator Driver's License No: [REDACTED]

Allergies or Health Concerns: N/A Blood Type: [REDACTED] Current Medications: [BLANK]

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

Emergency Contacts: 1. Name: Kishma Relationship: Friend Phone: [REDACTED]

2. Name: Demitri Relationship: Son Phone: [REDACTED]

Disclosure: "This information is for your safety and the safety of others."

Names mentioned: - Peter St Orner — Employee, Operator at LSJE, LLC - Kishma — Emergency contact, listed as Friend - Demitri — Emergency contact, listed as Son