23434 LEIN Request.pdf
PDF 165 KB Posted
- Attached to
- 472/23434. CTS; STF Paging Systems
- Solicitation number
- RFQ 171 240000000630 3
- Issued by
- Macomb County, Sterling Village, Michigan
About this file
This file is a LEIN (Michigan Law Enforcement Information Network) Request Form CAJ-1037 issued by the Michigan Department of Corrections (MDOC) for a project involving the St. Louis Central Michigan Correctional Facility Paging System Upgrades (File #472/23434.CTS). The form is designed to collect personal identification information and authorization for criminal history background checks for individuals requiring access to MDOC secure facilities. The document requests standard identification data including driver's license or state ID number, date of birth, race, and sex, along with the individual's full address and designation of their role (HR personnel, contractor, visitor, volunteer, or other representative). The form requires the individual's signature authorizing MDOC to conduct a criminal history check and, for employment purposes, to review motor vehicle operator license records to determine eligibility to operate vehicles during departmental business.
The form includes sections for MDOC personnel to document completion of the LEIN check, clearance status, and any relevant comments. No pricing, contract terms, funding sources, or award information is contained in this document, as it functions solely as a background check authorization and screening tool for facility access rather than a procurement or contract specification document.
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Text version
MICHIGAN DEPARTMENT OF CORRECTIONS
LEIN REQUEST
CAJ-1037.
REV. 09/19.
Please provide the information requested below. This information will be used to complete a criminal history check in the Michigan Law Enforcement Information Network (LEIN).
Your Driver’s License Number or State Identification Card Number, date-of-birth, race and sex is needed to complete this LEIN request.
Employment/Human Resources HR Personnel / Requesting
Contractor Visitor Contractor Agency Agency Representing
Volunteer Other Agency Representing Agency Representing Are you entering the secure perimeter/property of a Michigan Department of Corrections (MDOC) facility? Yes No
Please print information below:
Last Name: First Name: Middle Name:
Address:
City: State: Zip Code:
Date of Birth: Sex: Race:
Please provide the number of one of the following types of identification:
Driver’s License #: State issued by:
State ID #: State issued by:
I authorize the MDOC to conduct a criminal history check, so that I may be approved to enter the secure perimeter/property of an MDOC facility to perform work, visit, meet with or work with MDOC offenders.
For MDOC HR/Employment purposes only: I further authorize the Department to check my motor vehicle operator license record for the purposes of determining if I will be allowed to operate a motor vehicle while conducting Department business.
Signature: Date:
LEIN Completed By: Name: Date:
LEIN Cleared: Yes No (Does not apply to Human Resources)
MDOC Employment/HR purposes: Indicate the # of convictions:
Comment (Optional):
hallt2 Text Box Facility/Project Name: ST. LOUIS – Central Michigan Correctional Facility – Paging System Upgrades File # 472/23434.CTS kdillinger Typewritten Text kdillinger Typewritten Text
File details come from the government source that posted it. Updated .