EFTA00003070

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DOJ Data Set 1

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'NO 
a 
Today's Date: 
Employee Name: 
Physical Address, 
Mailing Address: 
Cell Phone: 
E-mail: 
LSJE, LLC 
6I 
ok 
uarters. Suite 13-3, St. Thomas, VI 00802-1348 
Phi 
E-mail: thesaintjamcs.group(a)gmail.com 
I mergency Contact Form 
01/11/18 
Sylvester Gaillard 
fide/Position: 
Kupenesor 
Allergies or Health Concerns: None 
riabetic Medications 
Current Medications: 
Doctors Name: 
Doctor's Name: 
Dr. Alah 
In case of emergency, please contact: 
Name: 
Name: 
St Thomas, V1 
Relationship: 
Relationship: 
Stan Date: 
Date of Birth: 
StThomas, VI 
IMOther 
Phone (other): 
Marital Status: 
Driver's License No: 
Doctor's Phone: 
Doctor's Phone: 
Single 
Phone: 
Phone: 
This information is for your safety and the safety of others 
0 Unknown 
11
EFTA00003070

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