CAJ-1037 MDOC LEIN Request REV 09-2019.pdf
PDF 173 KB Posted
- Solicitation number
- RFP-171-250000003010-1
- Issued by
- Alger County, Michigan
About this file
This document is a Michigan Department of Corrections (MDOC) Law Enforcement Information Network (LEIN) Request form, specifically designed for individuals seeking to enter a secure MDOC facility. The form is used to conduct criminal history checks for contractors, visitors, volunteers, or other personnel who may need access to correctional facilities. The form requires detailed personal identification information, including name, address, date of birth, race, sex, and either a driver's license or state ID number.
The form authorizes MDOC to perform a comprehensive background check, including criminal history and motor vehicle operator license verification. By signing the document, the individual grants permission for MDOC to review their records to determine eligibility for facility entry or employment. The form includes sections for MDOC personnel to complete, such as LEIN clearance status and the number of convictions, with spaces for optional comments. The specific facility noted on this document is the Alger Correctional Cooler Freezer/Roofs project, as indicated in the header.
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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):
BarschJ Text Box Facility/Project Name: Alger Correctional Cooler Freezer/Roofs File # 472/25256.JBB
File details come from the government source that posted it. Updated .