LEIN Request 23158.pdf
PDF 165 KB Posted
- Solicitation number
- RFQ 171 260000000476 2
- 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 used to collect personal identification information—including driver's license or state ID number, date of birth, race, and sex—from individuals seeking access to MDOC secure facilities. The form applies to employment and human resources personnel, contractors, visitors, volunteers, and agency representatives who need to enter the secure perimeter or property of an MDOC facility to perform work, conduct visits, or interact with MDOC offenders. Requesters must authorize the MDOC to conduct criminal history checks and, for employment purposes, motor vehicle operator license record checks to determine eligibility for facility access and vehicle operation privileges during departmental business.
The form requires completion and signature by the requesting individual, with processing and clearance documented by MDOC LEIN personnel. For MDOC employment and human resources purposes, the form includes fields to document the number of convictions and optional comments regarding the background check results. This administrative document serves as the gatekeeping mechanism to ensure that individuals working on or visiting the Carson City Correctional Facility project meet security and eligibility requirements established by the Michigan Department of Corrections.
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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 .