CAJ-1037 MDOC LEIN Request REV 09-2019.pdf
PDF 173 KB Posted
- Solicitation number
- RFP 171 250000003010 3
- Issued by
- Alger County, Michigan
About this file
This is a Law Enforcement Information Network (LEIN) Request Form issued by the Michigan Department of Corrections (MDOC) for criminal history background checks. The form, designated CAJ-1037 and revised in September 2019, is used to process background clearances for individuals seeking access to MDOC secure facilities and properties. The form applies to employment candidates, contractors, visitors, volunteers, and other individuals requiring entry to perform work, conduct visits, or interact with MDOC offenders. Required information includes personal identification details such as driver's license or state identification number, date of birth, race, sex, and full legal name with address information to complete the criminal history check through Michigan's law enforcement database.
The form authorizes MDOC to conduct comprehensive background investigations and, for HR and employment purposes, permits the Department to review motor vehicle operator license records to determine eligibility for operating vehicles during Department business. Requestors must provide a signature and date authorizing the LEIN check, and MDOC personnel complete the form by documenting the completion date and clearance status. The form indicates whether convictions exist and includes space for optional comments. The referenced facility and project in this instance is the Alger Correctional Cooler Freezer/Roofs project, identified by file number 472/25256.JBB.
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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 .