26156.MDL Chippewa CF Sanitary Swr. & Infrastructure - MDOC-LEIN_RequestForm.pdf
PDF 83 KB Posted
- Solicitation number
- RFQ 171 270000000012 7
- Issued by
- Michigan
About this file
This is a LEIN (Michigan Law Enforcement Information Network) Request Form CAJ-1037, issued by the Michigan Department of Corrections, used to conduct criminal history checks for individuals requiring access to secure perimeters or properties at MDOC facilities in connection with the Chippewa Correctional Facility Sanitary Sewer Upgrades project (472/26156.MDL). The form is completed by employment/human resources personnel or requesting contractors and serves as a prerequisite for approving vendor and contractor personnel to enter secure facility areas to perform work related to the project.
The form requests standard identification information including driver's license or state identification numbers, date of birth, race, and sex to facilitate the background check process. Individuals must authorize MDOC to conduct the criminal history check and, for MDOC employment purposes, authorize verification of motor vehicle operator license records for those operating vehicles during Department business. The form documents whether the LEIN check has been completed and cleared, with space for notation of any convictions and optional comments. Completion and clearance of this background check requirement is a necessary compliance step for all personnel accessing MDOC facilities in connection with the sanitary sewer infrastructure 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 .