LEIN Request 17436.pdf
PDF 123 KB Posted
- Solicitation number
- RFQ - 171 - 230000000296
- Issued by
- Luce County, Michigan
About this file
The document is a LEIN Request form from the Michigan Department of Corrections (MDOC) for a criminal history check to approve an individual to enter the secure perimeter/property of an MDOC facility to perform work, visit, meet with, or work with MDOC offenders. The form requires the individual's personal information, such as name, address, date of birth, sex, race, and driver's license or state ID number. The form also includes the Facility/Project Name as "Newberry CF - Wastewater Improvements Project" and the File # as 472/17436.TAP.
The related state and local contract opportunity is for the Newberry CF - Wastewater Improvements Project, File # 472/17436.TAP, located in Luce County, Michigan. The project involves wastewater improvements at the Newberry Correctional Facility. Interested bidders are instructed to submit questions via email to Jeremy Gagnon at jgagnon@upea.com, and bid attachments must be uploaded to the SIGMA VSS system. The bid submission deadline is 2:00 p.m., and emailed submissions may be considered on a case-by-case basis if approved by the Department of Design and Construction.
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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: Newberry CF - Wastewater Improvements Project File # 472/17436.TAP
File details come from the government source that posted it. Updated .