LSJE, LLC 6100 Red Hook Quarter B3 St. Thomas, VI 00802 Ph: Disciplinary Action Form Employee Name: Occupation: Manager/Supervisor: Date of Incident(s) Time of Incident: Occurance(s) leading to Discipline: Action taken: Date: Time: Employee Response: Date: Time: 1st Warning: Date _/ / Verbal: Written: 2nd Warning: Date /_I_ Verbal: Written: 3nd Warning: Date / / Verbal: Written: ACTION TAKEN: WARNING [ ] SUSPENSION [ ] TERMINATION [ ] with pay: Length of Suspension: without pay: This report will be included in the employee's Personnel File: Signature of Manager Date Signature of Supervisor Date Signature of Employee Date EFTA01099324