LEIN Request 17396 Bid Pack 3A.pdf
PDF 31 KB Posted
- Solicitation number
- RFQ-171-180000000556-2
- Issued by
- Michigan
About this file
This is a Michigan Department of Corrections (MDOC) Vendor/Contractor LEIN Request form (CAJ-1037) associated with the Various CF - Razor Ribbon Project (File #472/17396.SMD). The form is used to conduct criminal history background checks through the Michigan Law Enforcement Information Network (LEIN) for vendors and contractors who need to enter 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 number, state ID number, or Social Security number. The form includes an authorization section for the background check and a "Staff Use Only" section for MDOC personnel to document the reason for the check, staff involved, and whether the LEIN check was cleared. If not cleared, applicants are directed to obtain their Michigan criminal history through www.michigan.gov/ichat for a fee.
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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 hallt2 Text Box Facility/Project Name: Various CF - Razor Ribbon Project File # 472/17396.SMD
File details come from the government source that posted it. Updated .