Authorization #
Authorization Form
QPassport ID: Q06617528
FormFox Q06617528
Order Expiration Date/Time: 05/31/2023 11:59 PM
Subject Information
Employer Information
Name:
ID:
Phone:
Name:
Company:
Address:
Gentil Ntwari
TX-45265192
(832)994-375
Phone:
Bob Star Group Inc
DOT Con/CLIENT #58933
260 Northland Blvd Ste 303 B
Cincinnati, OH 45246
(419)314-3131
Test Authority: DOT - FMCSA
Service(s) to be Performed
PRE EMPLOYMENT - 1
Urine
Quest Diagnostics - (65304N)
Additional Information
Clinic Information
MasterMed LLC - Bensenville
1280 Mark St
Bensenville, IL 60106
Phone#: 630-422-7497 Fax#:
M-F 8:00 am-6:00 pm,Sa 8:00 am-3:00 pm;
rug Screen: M-F 8:00 am-6:00 pm,Sa 8:00 am-3:00 pm
Billing Information
Medical Review Officer
Do not bill if you are a preferred Quest or eScreen site.
NEW ERA DRUG TESTING
801 S Glenoaks Blvd Suite 200
Burbank, CA 91502
Name:
Company:
Address:
Phone #:
Fax #:
RAFFI KAZAZIAN
NEW ERA DRUG TESTING
801 S Glenoaks Blvd Suite 200
Burbank, CA 91502
(800) 801-0966
(818) 956-8275
Present this authorization form and a valid photo identification
05/19/2023
New Era Drug Testing
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