EFTA00003053

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DOJ Data Set 1

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LSJE, LLC 
6100 Red Hook Quarters Suite B-3 St. Thomas, VI 00802 Tel 
ax: 
Date: 
03/19/18 
Employee Name: GaSJ Leatham 
Address: 
Phone: 
Title / Position: Landscapi"g 
Emergency Contact Form 
Start Date: 
Date of Birth: 
E-Mail: 
Marital Status: Single 
License: 
/4 
4Thergency Informatioi, 
Allergies or Health Concerns: 
Blood Type: 
Current Medication: 
Doctor's Name: 
Doctor's Name: 
Phone: 
Phone: 
In case of an Emergency, Please contact: 
Name 
),me 
Relationship 
Girlfriend 
Phone 
Relationship 
Sister 
Phone 
This Information is for your safety and the safety of others 
EFTA00003053

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