LEIN Request 24264.pdf
PDF 165 KB Posted
- Solicitation number
- RFQ 171 260000000372 2
- 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 related to the Bellamy Creek Correctional Facility Paging System Replacement project (File #472/264.JGH). The form is used to collect personal information and authorization from individuals requiring access to secure perimeters or properties at MDOC facilities to perform work, conduct visits, or interact with MDOC offenders. Required information includes the applicant's full name, date of birth, address, sex, race, and identification number (driver's license or state ID). The form authorizes MDOC to conduct a criminal history check and, for employment purposes, to review motor vehicle operator license records to determine eligibility for operating vehicles during Department business.
The form is completed and signed by the individual seeking access, then processed by MDOC personnel who verify clearance status through the LEIN system. The clearance determination is documented with a "Yes" or "No" indication of approval. For MDOC employment and human resources purposes, the form includes notation of conviction counts and optional comments. This background check process is a prerequisite for contractors and personnel involved in the Bellamy Creek facility project to gain authorized entry to the secure facility.
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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 .