LSJE, LLC [EFTA00003048]

LSJE, LLC \n6100 Red [look Quarters Suite B-3 St. Thomas, VI 00802 Tel: \nax: \nDate: \n)4'10/18 \nEmployee Name: Deice Gusneme \nAddress: \nPhone: \nle / Position- \n..—\nL:41. \nZIF.mergeocy Informal it \nAllergies or Health Concerns: \nBlood Type: \nCurrent Medication: \nEmergency Contact Form \nStart Date: \nDate of Birth:!\nE-Mail: \nMarital Status: Married \nLicense: \nBlood type not specified \nDoctor's Name: \nPho►re: \nDoctor's Name: \nPhone: \nIn case of an Emergency, Please contact : \nRelationship \nSister \nPhone \nRelationship \nPhone \nThis Information is for your safety and the safety of others \nEFTA00003048\n\n--- Page Break ---\n\nLSJE, LLC \n6100 Red [look Quarters Suite B-3 St. Thomas, VI 00802 Tel: \nax: \nDate: \n)4'10/18 \nEmployee Name: Deice Gusneme \nAddress: \nPhone: \nle / Position- \n..—\nL:41. \nZIF.mergeocy Informal it \nAllergies or Health Concerns: \nBlood Type: \nCurrent Medication: \nEmergency Contact Form \nStart Date: \nDate of Birth:!\nE-Mail: \nMarital Status: Married \nLicense: \nBlood type not specified \nDoctor's Name: \nPho►re: \nDoctor's Name: \nPhone: \nIn case of an Emergency, Please contact : \nRelationship \nSister \nPhone \nRelationship \nPhone \nThis Information is for your safety and the safety of others \nEFTA00003048