LEIN Request 24054.pdf

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: Gus Harrison CF - Paving and Concrete Replacement File # 472/24054.DPL