LEIN Request 23206.pdf
PDF 123 KB Posted
- Solicitation number
- RFQ - 171 - 230000000445
- Issued by
- Jackson County, Michigan
About this file
This document is a LEIN Request form from the Michigan Department of Corrections (MDOC) for a criminal history check to allow individuals to enter secure MDOC facilities. The form requests personal information such as name, address, date of birth, driver's license number, and authorization to conduct the LEIN check and motor vehicle record check.
The related state and local contract opportunity is for the Cooper Street Correctional Facility Wi-Fi Cabling Infrastructure project, contract number 472/23206.RWG. The project entails the installation of a Wi-Fi cabling infrastructure at the Cooper Street Correctional Facility, located in Jackson County, Michigan. The procurement documents provide instructions for submitting questions, uploading bid attachments to the SIGMA VSS system, and procedures for emailing proposals if there are issues with the electronic submission.
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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: Cooper Street CF - Wi-Fi Cabling Infrastructure File # 472/23206.RWG
File details come from the government source that posted it. Updated .