LSJE, LLC 6100 Red [look Quarters Suite B-3 St. Thomas, VI 00802 Tel: ax: Date: )4'10/18 Employee Name: Deice Gusneme Address: Phone: le / Position- ..— L:41. ZIF.mergeocy Informal it Allergies or Health Concerns: Blood Type: Current Medication: Emergency Contact Form Start Date: Date of Birth:! E-Mail: Marital Status: Married License: Blood type not specified Doctor's Name: Pho►re: Doctor's Name: Phone: In case of an Emergency, Please contact : Relationship Sister Phone Relationship Phone This Information is for your safety and the safety of others EFTA00003048