LEIN Request 23158.pdf
PDF 165 KB Posted
- Solicitation number
- RFQ 171 260000000476 1
- Issued by
- Michigan
About this file
This is a Law Enforcement Information Network (LEIN) Request Form issued by the Michigan Department of Corrections (MDOC) for criminal history background checks. The form is associated with the Carson City Correctional Facility - Cell Door Locks and Controls Upgrades project (File # 472/23158.TYC). The LEIN Request form is utilized to screen individuals requiring access to secure perimeters or properties at MDOC facilities, including employment applicants, contractors, visitors, and volunteers. The form requires collection of personal identification information including driver's license or state identification card number, date of birth, race, and sex to facilitate the criminal history check through Michigan's Law Enforcement Information Network.
The form authorizes the MDOC to conduct comprehensive criminal history checks for individuals seeking approval to enter secure facility areas for work, visitation, or engagement with offenders. For MDOC Human Resources and employment purposes, the Department is additionally authorized to review motor vehicle operator license records to determine eligibility for operating vehicles during Department business. The form requires the applicant's signature and authorization, with completion documented by MDOC personnel including the name and date of the LEIN check and clearance status. The form includes provisions for recording conviction information and optional comments by HR personnel conducting the background screening.
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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: Carson City Correctional Facility - Cell Door Locks and Controls Upgrades File # 472/23158.TYC
File details come from the government source that posted it. Updated .