LEIN Request 22426.pdf
PDF 129 KB Posted
- Attached to
- 472/22426. CTS; CMCF - Various Security Upgrades
- Solicitation number
- RFQ 171 240000000205 2
- Issued by
- Gogebic County, Sterling Heights City, Michigan
About this file
This is a LEIN (Michigan Law Enforcement Information Network) Request Form from the Michigan Department of Corrections (MDOC) used for criminal history background checks. The form is associated with the CMCF - Various Security Upgrades project (File #472/22426.CTS) and is designed to collect personal information and identification details from individuals requiring access to secure perimeters and properties of MDOC facilities. The form requests applicant information including name, date of birth, address, sex, race, and driver's license or state identification card number. Individuals must indicate whether they are entering the secure perimeter of an MDOC facility and identify their role, such as employment/human resources personnel, contractor, visitor, volunteer, or other representative.
The form requires applicant authorization for MDOC to conduct a criminal history check to determine eligibility to enter secure MDOC facility areas for work, visits, meetings, or work involving MDOC offenders. For MDOC employment and human resources purposes, applicants further authorize the Department to review motor vehicle operator license records to determine eligibility to operate vehicles while conducting Department business. The completed form includes sections for MDOC personnel to document whether the LEIN check has been completed and cleared, with optional notation of conviction records and comments. This screening document is a prerequisite for access and participation in MDOC-related projects and operations.
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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: CMCF - Various Security Upgrades File # 472/22426.CTS
File details come from the government source that posted it. Updated .