LEIN Request 22064.pdf
PDF 174 KB Posted
- Attached to
- 472/22064. CTS; Saginaw CF - HVAC Renovations
- Solicitation number
- RFQ-171-250000000200-3
- Issued by
- Saginaw County, Flint City, Michigan
About this file
This document is a LEIN (Law Enforcement Information Network) Request form (CAJ-1037) from the Michigan Department of Corrections (MDOC) associated with the Saginaw CF - HVAC Renovations project (File #472/22064.CTS). The form is used to conduct criminal history checks for individuals who need to enter MDOC facilities, whether as employees, contractors, visitors, or volunteers. The document requires personal identification information including driver's license or state ID number, date of birth, race, and sex.
The form includes authorization for MDOC to conduct criminal background checks for facility access and, specifically for HR/Employment purposes, authorization to check motor vehicle operator license records. The form must be completed with personal information, identification details, and a signature authorizing the background check. The bottom section is reserved for official use, including fields for LEIN completion verification, clearance status, and conviction records for employment purposes.
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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: Saginaw CF - HVAC Renovations
File # 472/22064.CTS
File details come from the government source that posted it. Updated .