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 Page 1