CAJ-1037 DOC LEIN Request REV 04-2018.pdf
PDF 24 KB Posted
- Solicitation number
- RFQ 171 190000000172 2
- Issued by
- Kalamazoo County, Michigan
About this file
This is a criminal history clearance request form issued by the Michigan Department of Corrections (MDOC) for vendors and contractors requiring access to MDOC facilities. The form, designated CAJ-1037 (Revision 04/18), is used to initiate a criminal history check through the Michigan Law Enforcement Information Network (LEIN) prior to facility entry authorization. The form requires prospective vendors and contractors to provide personal identification information including driver's license or state identification card number, date of birth, race, and sex. Completion and clearance of the LEIN check is mandatory for any individual seeking to visit or conduct business with persons confined in Michigan Department of Corrections facilities. The form includes spaces for facility or project name identification and file number assignment for administrative tracking purposes.
The form authorizes MDOC to conduct a comprehensive criminal history check as a prerequisite for facility access approval. Vendor and contractor applicants must personally sign and date the authorization statement, and MDOC staff complete the verification process by documenting the LEIN check results, clearance status (yes or no), and initialing the completion with date. Additional criminal history information is available to applicants through the Michigan state website at www.michigan.gov/ichat, though a fee applies for obtaining copies of individual criminal histories.
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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 .