26156.MDL Chippewa CF Sanitary Swr. & Infrastructure - MDOC-LEIN_RequestForm.pdf
PDF 83 KB Posted
- Solicitation number
- RFQ 171 270000000012 3
- Issued by
- Michigan
About this file
This document is a Michigan Law Enforcement Information Network (LEIN) Request Form (CAJ-1037) issued by the Michigan Department of Corrections (MDOC) for the Chippewa Correctional Facility Sanitary Sewer Upgrades project (472/26156.MDL). The form is used to conduct criminal history checks for individuals requiring access to secure perimeters or property at MDOC facilities to perform work, conduct visits, or interact with MDOC offenders. The form requires collection of personal identification information including driver's license or state identification card number, date of birth, race, and sex. Individuals must authorize the MDOC to conduct the criminal history check and, for HR/employment purposes, authorize checks of motor vehicle operator license records to determine eligibility to operate vehicles during Department business.
This is a pre-employment and facility access screening document rather than a procurement specification. The form does not contain pricing information, contract terms, set-asides, funding sources, or other financial procurement details. It functions as an administrative requirement that contractors and personnel working on or visiting the Chippewa Correctional Facility project must complete prior to accessing the secure facility. The form includes sections for MDOC HR personnel to indicate the number of convictions and provide optional comments, with clearance determined by MDOC security protocols.
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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 .