LEIN Request 17032 St Louis.pdf
PDF 123 KB Posted
- Solicitation number
- RFQ 171 250000000456 2
- Issued by
- Gogebic County, Sterling Heights City, Michigan
About this file
This is a Michigan Department of Corrections (MDOC) Law Enforcement Information Network (LEIN) Request form used to conduct criminal history checks for individuals seeking access to secure facilities. The form is associated with the St. Louis Correctional Facility WiFi Cabling Infrastructure project (File #472/17032.RWG). The LEIN request form CAJ-1037 (Revised 09/19) collects personal identification information including driver's license or state identification number, date of birth, race, and sex from employment candidates, contractors, visitors, volunteers, or other individuals requiring entry to MDOC secure perimeters or properties. The form requires authorization from the subject individual to allow MDOC to conduct the criminal history check and, for employment purposes, to review motor vehicle operator license records to determine eligibility for operating vehicles during Department business.
The form does not contain pricing information, set-asides, incumbent details, or funding sources. This is a screening and compliance document designed to facilitate background vetting rather than a procurement document outlining contract terms or project specifications. Completion of the LEIN request is a prerequisite for any personnel or contractor approval to work on or access MDOC facilities related to the St. Louis facility infrastructure project.
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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: St Louis CF - WiFi Cabling Infrastructure File # 472/17032.RWG
File details come from the government source that posted it. Updated .