26156.MDL Chippewa CF Sanitary Swr. & Infrastructure - MDOC-LEIN_RequestForm.pdf
PDF 83 KB Posted
- Solicitation number
- RFQ 171 270000000012 2
- Issued by
- Chippewa County, Michigan
About this file
This is a criminal history check request form used by the Michigan Department of Corrections (MDOC) to process background clearances for individuals seeking access to secure MDOC facilities. The form, designated CAJ-1037 (Revised 09/19), serves as the official LEIN (Michigan Law Enforcement Information Network) request document and applies to employment candidates, contractors, visitors, volunteers, and other individuals requiring entry to MDOC secure perimeter property. The form collects standard identification information including driver's license or state identification card number, date of birth, race, and sex necessary to complete the criminal history check through the LEIN system. Requesters must indicate their purpose for facility access and whether they will enter the secure perimeter, and they authorize MDOC to conduct the background investigation as a condition of approval. For MDOC human resources and employment purposes, the form includes an optional section for motor vehicle operator license record checks to determine eligibility to operate vehicles on Department business.
The form requires individuals to provide personal identifying information and sign an authorization statement permitting MDOC to access criminal history records through LEIN. MDOC personnel completing the request form must document their name, date completed, and clearance status (Yes/No), with an optional comments section available to indicate the number of convictions or other relevant information. The clearance notation does not apply to Human Resources employment purposes, indicating differentiated processing procedures based on the type of access request. This document functions as an internal administrative tool rather than a procurement or contract document, serving solely to facilitate background screening and facility access authorization.
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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 .