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 2
- Issued by
- Chippewa County, Michigan
About this file
This is a LEIN (Law Enforcement Information Network) Request Form CAJ-1037, Revision 09/19, issued by the Michigan Department of Corrections (MDOC) in connection with the Kinross Correctional Facility PA Upgrades project (472/25139.ABG). The form is designed to facilitate criminal history checks for individuals requiring access to MDOC secure facilities and properties. The document requests personal identification information including driver's license or state identification card number, date of birth, race, and sex to complete the LEIN background check. The form accommodates multiple categories of individuals, including employment and human resources personnel, contractors, visitors, volunteers, and agency representatives seeking approval to enter secure perimeters or work with MDOC offenders.
The form requires individuals to authorize MDOC to conduct criminal history checks and, for employment purposes, to review motor vehicle operator license records to determine eligibility for operating vehicles during Department business. The completed form must be signed and dated by the applicant, with LEIN clearance documented by the completing official. For MDOC employment and human resources purposes, the form includes space to indicate the number of convictions and optional comments. This administrative document serves as a prerequisite screening tool for the PA Upgrades project at the Kinross facility and does not contain pricing terms, contract amounts, or specific project deliverables beyond the background screening requirement.
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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 .