EFTA01342063

LS E LLC Emergency Contact Form Date: 04/09/18 Employee Name: Onel Pierresaint Address: Phone: Title / Position: I nergency Information: Blood type unspecified Allergies or Health Concerns: Losartan Potassium 50 mg Tab Doctor's Name: Rosal Joselito Doctor's Name: In case of an Emergency, Please contact : Start Date: Date of Birth:■ E-Mail: Marital Status: Married License: L Phone: Phone: Name Rose Marie Jean Baptiste Relationship Wife Phone glI3 me Robenio Joseph Relationship Friend Phone This Information is for your safety and the safety of others EFTA01342063