Correction Lein Form.pdf
PDF 79 KB Posted
- Attached to
- Central Michigan Correctional - Fire Alarm Upgrade State and local contract opportunity
- Solicitation number
- RFQ-171-180000000115-5
- Issued by
- Sanilac County, Michigan
About this file
This is a Vendor/Contractor LEIN Request form (CAJ-1037) from the Michigan Department of Corrections used to conduct criminal history checks through the Michigan Law Enforcement Information Network (LEIN) for vendors and contractors seeking access to MDOC facilities. The form requires applicants to provide personal identification information including name, address, date of birth, sex, race, and at least two forms of identification from among driver's license, state ID, or Social Security number.
The form includes a staff-use section for documenting the reason for the LEIN check, staff requesting and conducting the check, and whether the check was cleared. If an applicant does not clear the LEIN check, they are directed to obtain a copy of their Michigan criminal history through www.michigan.gov/ichat for a fee. The form requires the applicant's signature authorizing MDOC to conduct the criminal history check for facility access purposes.
View the file
Other files for this state and local contract opportunity
| File | Type | Posted |
|---|---|---|
| Sign In 171030.pdf | ||
| Addendum 1 16344.pdf | ||
| 16344 Advertisement.doc | DOC document | |
| 16344 Specifications.pdf |
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Text version
MICHIGAN DEPARTMENT OF CORRECTIONS
VENDOR/CONTRACTOR LEIN REQUEST
CAJ-1037
REV. 03/15
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 and your Social Security 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 at least two of the following three types of identification:
Driver’s License # State issued by
State ID # State issued by
Social Security #
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
File details come from the government source that posted it. Updated .