Starline cargo llc

---

Authorization Form

Authorization #

Name:

STARLINE CARGO LLC

Address:

5533 SOUTHWYCK BLVD 101 DAVRANBEK TAYL

TOLEDO, OH 43614

Phone #:

Phone#: [phone]  

Name:

Adefusi  Ebenezer

Drivers License:

45598430

Individual Information

Hiwet Clinic of Texas

6910 Bellaire Blvd Ste 14

Houston, TX 77074-3547

Phone#: [phone] 

Monday, Tuesday, Wednesday, Thursday, Friday   09:00 - 

18:00

Saturday   10:00 - 15:00

Sunday CLOSED

Site Information

Additional Information

pre-employment 

Service(s) to be Performed

DOT Urine

PRE-EMPLOYMENT - 1

Quest Diagnostics - 11393465 - (65304N) DOT DRUG PANEL W/TS Split Urine - 

*Not Observed*

Present this authorization form and a valid photo identification

Medical Review Officer

Billing Information

Starline Cargo LLC

Name:

MARTIN PIERETTI, DO MPH

Address:

1432 EASTON RD STE 3CSECURE RESULTS

WARRINGTON, PA 18976

Phone #:

[phone]

Employer Information

** ATTENTION **

Call the site to confirm their hours of operation and if an appointment is required

Experiencing technical issues? Please contact the technical support team at 877-376-3691.

**FormFox is 

NOT

 responsible for paying for these services.**