25139.ABG Kinross PA - MDOC-LEIN_RequestForm.pdf
PDF 83 KB Posted
- Attached to
- 472/25139. ABG; Kinross C. F. - PA Upgrades
- Solicitation number
- RFQ 171 260000000460 1
- Issued by
- Cass County, Michigan
About this file
This document is a LEIN Request Form (CAJ-1037, Revised 09/19) issued by the Michigan Department of Corrections (MDOC) for the Kinross Correctional Facility project (472/25139.ABG - PA Upgrades). The form is designed to facilitate criminal history background checks through the Michigan Law Enforcement Information Network (LEIN) for individuals requiring access to secure perimeters or properties at MDOC facilities. The form applies to employment candidates, contractors, visitors, volunteers, and other agency representatives who need approval to enter secure areas to perform work, conduct visits, or interact with MDOC offenders. Requestors must provide personal identification information including driver's license or state identification card number, date of birth, race, sex, and current address to complete the background check process.
The form requires individuals to authorize the MDOC to conduct a comprehensive criminal history check and, for employment or HR purposes, to review motor vehicle operator license records to determine eligibility for operating vehicles during Department business. The form includes signature and date fields for the applicant, as well as completion and clearance verification fields for MDOC LEIN personnel. A comment section is provided for MDOC HR/Employment purposes to document the number of convictions and any additional relevant information. This form serves as a mandatory screening requirement prior to facility access approval for the Kinross Correctional Facility project.
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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):
File details come from the government source that posted it. Updated .