EFTA01342049

LSIE, LLC Emergency Contact Form Start Date: Date: 04/10/18 Employee Name: Dalce Gusneme Address: Date of Birth: 12/28/66 Phone: 340-643-4374 E-Mail: / Position: Marital Status: Married License: mergency Informatir Allergies or Health Concerns: Blood Type: Blood type no specified Current Medication: Doctor's Name: Phone: Doctor's Name: Phone: In case of an Emergency, Please contact : Name Licimene Dalce Relationship Sister JI. a me Relationship Phone This Information is for your safety and the safety of others • .•• V. Phone 340-344-1819 EFTA01342049