LEIN Request 24055.pdf
PDF 174 KB Posted
- Solicitation number
- RFQ 171 260000000384 3
- 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 specifically associated with the Gus Harrison Correctional Facility's Smoke Purge System Repair/Replace project (File #472/24055.DPL). The LEIN Request Form CAJ-1037 is used to collect personal identification information and authorize MDOC to conduct criminal background checks for individuals seeking access to secure perimeters or properties at MDOC facilities. The form requires applicants to provide driver's license or state identification numbers, date of birth, race, sex, and full address information. Requesters must indicate whether they are entering the secure perimeter as employment/HR personnel, a requesting contractor, visitor, contractor agency representative, volunteer, or other designee.
The form authorizes the MDOC to access criminal history records through the Michigan Law Enforcement Information Network and, for HR/employment purposes only, permits the Department to review motor vehicle operator license records to determine eligibility to operate vehicles during Department business. The form includes fields for documenting the number of convictions and optional comments, with designation of whether the applicant has been cleared for facility access. This administrative document serves as a prerequisite screening mechanism for all individuals requiring access to MDOC facilities in connection with the Gus Harrison facility's smoke purge system repair or replacement project.
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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: Gus Harrison C.F. - Smoke Purge System Repair/ Replace
File # 472/24055.DPL
File details come from the government source that posted it. Updated .