LEIN Request 24264.pdf
PDF 165 KB Posted
- Solicitation number
- RFQ 171 260000000372 1
- Issued by
- Michigan
About this file
This is a LEIN (Law Enforcement Information Network) Request Form CAJ-1037 from the Michigan Department of Corrections (MDOC) related to the Bellamy Creek Correctional Facility Paging System Replacement project (File #472/264.JGH). The form is a criminal history background check authorization document required for individuals seeking access to the secure perimeter or property of an MDOC facility to perform work, conduct visits, or interact with MDOC offenders. The form collects standard identification information including driver's license or state ID number, date of birth, race, sex, and full name and address of the individual requesting access.
The form serves as authorization for the MDOC to conduct a criminal history check through the Michigan Law Enforcement Information Network to determine eligibility for secure facility access. For MDOC Human Resources and employment purposes, the form also authorizes a motor vehicle operator license record check to assess whether the individual may operate a vehicle while conducting Department business. The form requires the signature and date of the requestor and completion information from the LEIN processing personnel, including whether the individual was cleared for facility access. A comments section is available for MDOC HR purposes to document any conviction information relevant to the employment or access decision.
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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: Bellamy Creek C.F. - Paging System Replacement File # 472/264.JGH
File details come from the government source that posted it. Updated .