CAJ-1037 MDOC LEIN Request REV 09-2019.pdf
PDF 159 KB Posted
- Solicitation number
- RFQ 171 240000000617 3
- Issued by
- Baraga County, Michigan
About this file
This is a LEIN (Law Enforcement Information Network) Request form issued by the Michigan Department of Corrections (MDOC) for conducting criminal history checks on individuals seeking access to secure MDOC facilities. The form is used to collect personal identification information and authorization for background screening of employment candidates, human resources personnel, contractors, visitors, volunteers, and other individuals representing agencies that need to enter the secure perimeter or property of MDOC facilities to perform work, conduct visits, meet with offenders, or work with MDOC staff. The specific project referenced is the MDOC Baraga Maximum Correctional Facility - Proposed HU-1 Yard Door (File #472/19344.TAP). Required information includes the applicant's full name, address, date of birth, sex, race, and a valid government-issued identification number such as a driver's license or state ID card.
The form serves as authorization documentation for MDOC to conduct criminal history checks and, for employment purposes only, to review motor vehicle operator license records to determine eligibility to operate vehicles while conducting Department business. Applicants must sign and date the form to authorize the background check. MDOC personnel complete the LEIN check and indicate whether the individual has been cleared for facility access, with notation of any convictions if applicable. This form is a standard administrative requirement for all categories of individuals requiring secure facility access and represents a standard operational control measure for correctional facility security.
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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: MDOC Baraga Maximum Correctional Facility - Proposed HU-1 Yard Door File # 472/19344.TAP
File details come from the government source that posted it. Updated .