CAJ-1037 DOC LEIN Request REV 04-2018.pdf
PDF 24 KB Posted
- Solicitation number
- RFQ-171-190000000172-2
- Issued by
- Kalamazoo County, Huntington Woods City, Michigan
About this file
This is a Vendor/Contractor LEIN Request form (CAJ-1037) from the Michigan Department of Corrections (MDOC) used to conduct criminal history background checks through the Michigan Law Enforcement Information Network (LEIN) for vendors and contractors seeking facility access. The form requires applicants to provide personal identification information including name, address, date of birth, race, sex, and either a driver's license number or state ID number. Approval of this background check is required before any vendor or contractor can visit or meet with persons confined in MDOC facilities.
The form includes a staff-use section where MDOC personnel document the reason for the LEIN check, who requested and performed it, and whether the check was cleared. If the check is not cleared, applicants are directed to obtain their Michigan criminal history through www.michigan.gov/ichat for a fee. The form requires the applicant's signature authorizing MDOC to conduct the background check, and includes fields for a facility/project name and file number to be recorded.
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Text version
MICHIGAN DEPARTMENT OF CORRECTIONS
VENDOR/CONTRACTOR LEIN REQUEST
CAJ-1037
REV. 04/18
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 is needed to complete this LEIN. Also needed are your date-of-birth, race and sex. Potential entry into MDOC facilities require that this LEIN check be completed and cleared.
Profession Vendor Contractor
Last Name (Please Print) 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 Michigan Department of Corrections to conduct a criminal history check, so that I may be approved to visit/meet with persons confined in a Michigan Department of Corrections facility.
Signature Date
Staff Use Only
Reason for LEIN Check
Staff requesting LEIN Check
LEIN Checked by
LEIN Clear Yes No, You may obtain a copy of your Michigan criminal history at www.michigan.gov/ichat. There is a fee for this service.
LEIN Check completed by Initials Date http://www.michigan.gov/ichat hallt2 Text Box Facility/Project Name: ________________________________ File # 472/_______.____
File details come from the government source that posted it. Updated .