LEIN Request 19019.pdf
PDF 123 KB Posted
- Solicitation number
- RFQ - 171 - 220000000569
- Issued by
- Washtenaw County, Chesaning Village, Michigan
About this file
The document provided is a LEIN Request form from the Michigan Department of Corrections. It is used to complete a criminal history check in the Michigan Law Enforcement Information Network (LEIN) for individuals seeking to enter the secure perimeter/property of a Michigan Department of Corrections (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 related state and local contract opportunity is for the SAI Facility - Various Building Demolitions project, identified as File #472/19019.TCY. This project is located in Washtenaw County and Chesaning Village, Michigan. The bid attachments must be uploaded to SIGMA VSS, and hard copies will not be accepted. Bidders are instructed to email questions to the project contact, Alex Koltowicz, and not submit questions through the VSS system. The bid submission deadline is 2:00 p.m. Emailed submissions may be accepted on a case-by-case basis with prior approval from 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: SAI - Various Building Demolitions File # 472/19019.TCY
File details come from the government source that posted it. Updated .