25476 Chippewa Roof Repairs - MDOC-LEIN_RequestForm.pdf
PDF 83 KB Posted
- Solicitation number
- RFQ-171-260000000040-2
- Issued by
- Chippewa County, Michigan
About this file
This document is a LEIN (Michigan Law Enforcement Information Network) Request Form issued by the Michigan Department of Corrections (MDOC) for conducting criminal history checks on individuals seeking access to MDOC facilities. The form is designed to collect personal identification information and demographic data from employees, human resources personnel, contractors, visitors, volunteers, and other individuals requiring entry to secure perimeters or properties of MDOC facilities. The requestor must provide their driver's license number or state identification card number, date of birth, race, and sex to complete the criminal history check. The form includes checkboxes to indicate the category of the individual (Employment/Human Resources, Contractor, Visitor, Volunteer, or Other) and their corresponding agency affiliation. Requestors must confirm whether they are entering the secure perimeter or property of an MDOC facility and provide authorization for the Department to conduct the criminal history check.
The form requires individuals to sign and date the authorization section, which grants MDOC permission to conduct a criminal history check for approval to enter secure areas and perform work, visit, or interact with MDOC offenders. For MDOC employment and human resources purposes, the form includes an additional authorization for checking motor vehicle operator license records to determine eligibility to operate vehicles during Department business. Upon completion, MDOC personnel must document the name and date of the LEIN completion, indicate whether the individual was cleared (Yes/No), note the number of convictions for employment purposes, and provide optional comments. The form number is CAJ-1037, revised September 2019.
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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 .