472.25086.JGH - LEIN Request (with project header).pdf
PDF 137 KB Posted
- Solicitation number
- RFQ 171 260000000275 1
- Issued by
- Huron County, Michigan
About this file
This is a LEIN (Law Enforcement Information Network) Request Form CAJ-1037 (Revised 09/19) issued by the Michigan Department of Corrections (MDOC) for criminal history background checks required for facility access. The form is associated with the Ionia Correctional Facility Exterior Door Replacement project (File #472/25086.JGH). The document serves as a prerequisite screening tool for individuals requiring access to the secure perimeter of MDOC facilities, including employment applicants, contractors, visitors, volunteers, and agency representatives. The form requires standard personal identification information including full name, date of birth, address, sex, race, and either a driver's license number or state identification card number to process the criminal history check through the Michigan Law Enforcement Information Network.
The LEIN request form includes authorization for MDOC to conduct comprehensive criminal history checks and, for HR/employment purposes only, motor vehicle operator license record checks for individuals who may operate Department vehicles during business activities. The form designates space for documenting the number of convictions and optional comments by MDOC personnel. Completion and clearance of the LEIN check are indicated through signature lines and date fields for both the requesting party and the MDOC personnel conducting the background investigation. This form represents a standard security and compliance requirement for any individual seeking legitimate access to MDOC secure facilities in connection with work, visits, or offender interactions.
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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 - Exterior Door
Replacement
File # 472/25086.JGH
File details come from the government source that posted it. Updated .