472-23280.SDW MDOC LEIN Request.pdf
PDF 165 KB Posted
- Solicitation number
- RFP 171 230000002396 2
- Issued by
- Chippewa County, Kincheloe CDP, Michigan
About this file
This is a criminal history check request form from the Michigan Department of Corrections (MDOC) used to screen individuals seeking access to secure MDOC facilities. The form, CAJ-1037 (revised 09/19), is designed to gather personal identification information including name, date of birth, address, sex, and race, along with driver's license or state identification card numbers necessary to conduct a background check through the Michigan Law Enforcement Information Network (LEIN). The form applies to various categories of individuals including employment applicants, contractors, human resources personnel, visitors, volunteers, and other agency representatives who require access to the secure perimeter or property of MDOC facilities to perform work, conduct visits, or interact with offenders. The requestor must authorize the MDOC to complete the criminal history check and, for HR and employment purposes, may also authorize a motor vehicle operator license record check to determine eligibility to operate vehicles during department business.
The form includes signature and date fields for the applicant and completion information for MDOC LEIN personnel, with space to indicate clearance status and note the number of convictions and optional comments for HR purposes. This document is associated with File #472/23280.SDW and the Northern Region Training Academy facility or project. There are no pricing terms, contract amounts, or financial considerations included in this screening document, as it functions solely as a background check authorization and clearance mechanism rather than a procurement or service contract.
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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):
hallt2 Text Box Facility/Project Name: Northern Region Training Academy File # 472/23280.SDW
File details come from the government source that posted it. Updated .