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LSJE, LLC

DOJ EFTA Data Set 10 document EFTA01304175

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DOJ EFTA Data Set 10 document EFTA01304175

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EFTA Disclosure
Text extracted via OCR from the original document. May contain errors from the scanning process.
LSJE, LLC 6100 Red Hook Quarters Suite B-3 St. Thomas, VI 00802 Tel: 340-775-8100 Fax: 340-775-8108 Emergency Contact Form Date: 06/14/18 Employee Name: Felito Joseph Address: ,)nurv- Pr'osition. mergency irc:c,:t— Allergies or Health Concerns: Blood Type: Current Medication: Doctor's Name: Doctor's Name: Marital Status: Single Phone: Phone: In case of an Emergency, Please contact : Name /Name Relationship Relationship Start Date: Date of Birth: Phone Phone This Information is for your safety and the safety of others M EFTA_00 192987 EFTA01304175

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FaxFax: 340-775-8108
Phone340-775-8100
Phone340-775-8108

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