472-24069.JGH Ionia CF Generator_LEIN Request REV 09-2019 (with project header).pdf
PDF 166 KB Posted
- Solicitation number
- RFQ 171 260000000274 1
- Issued by
- Huron County, Michigan
About this file
This is a LEIN (Law Enforcement Information Network) Request Form CAJ-1037 (Revision 09/2019) issued by the Michigan Department of Corrections for the Ionia Correctional Facility Generator, Switchgear Replacement, and Above-Ground Storage Tank (AST) project (File #472/24069.JGH). The form is designed to facilitate criminal history checks for individuals requiring access to secure perimeters or properties at Michigan Department of Corrections facilities. The document requests personal information including driver's license or state identification card number, date of birth, race, and sex from employment and human resources personnel, requesting contractors, visitors, contractors representing agencies, volunteers, or other designated representatives who need clearance to enter secure areas to perform work, visit, meet with, or work with MDOC offenders.
The form includes authorization provisions allowing the MDOC to conduct criminal history checks through the Michigan Law Enforcement Information Network and, for HR/employment purposes, to check motor vehicle operator license records to determine eligibility to operate vehicles while conducting Department business. The form requires signature and date from the applicant and includes completion fields for MDOC personnel to document whether the LEIN check was completed and whether the individual was cleared for facility access. Optional comment fields allow notation of conviction counts and additional relevant information regarding the applicant's clearance status.
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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: Ionia Correctional Facility - Generator, Switchgear Replacement, & AST
File # 472/24069.JGH
File details come from the government source that posted it. Updated .