LEIN Request 24263.pdf
PDF 135 KB Posted
- Attached to
- 472/24263. SAA; WHVCF - Roof Replacement Phase 2
- Solicitation number
- RFQ 171 260000000336 3
- Issued by
- Washtenaw County, Michigan
About this file
This is a Law Enforcement Information Network (LEIN) request form from the Michigan Department of Corrections (MDOC) used to conduct criminal history checks for individuals seeking access to secure perimeters at MDOC facilities. The form is associated with the WHVCF Prisoner Service Building and Fieldhouse Roof Replacement project (File #472/24263.SAA). The LEIN request applies to employment and human resources personnel, requesting contractors, visitors, volunteers, and other individuals representing agencies that need to enter secure MDOC property to perform work, conduct visits, or interact with MDOC offenders. The form requires collection of personal identification information including driver's license or state ID number, date of birth, race, and sex to facilitate the background check process.
The LEIN request form is a prerequisite administrative document rather than a procurement specification and does not contain pricing terms, contract award information, or funding requirements. Individuals or contractors must complete and submit the form authorizing MDOC to conduct criminal history checks and, for employment purposes, to review motor vehicle operator license records. The form includes spaces for MDOC personnel to document completion of the LEIN check, clearance status, conviction records, and optional comments. This administrative requirement applies to all parties seeking access to the secure facility areas related to the Prisoner Service Building and Fieldhouse Roof 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: WHVCF - Prisoner Service Building and Fieldhouse Roof Replacement File # 472/24263.SAA
File details come from the government source that posted it. Updated .