LEIN Request 24428.pdf
PDF 174 KB Posted
- Solicitation number
- RFQ-171-250000000252-3
- Issued by
- Washtenaw County, Michigan
About this file
This document is a Law Enforcement Information Network (LEIN) Request form from the Michigan Department of Corrections (MDOC), specifically associated with the WHVCF - EM Room & Control Ctr Renovation project (File # 472/24428.SAA). The form is designed to conduct criminal history checks for individuals seeking to enter secure MDOC facility perimeters, including contractors, volunteers, visitors, or personnel performing work with or near offenders.
The form requires detailed personal identification information, including name, address, date of birth, race, sex, and either a driver's license or state identification number. Individuals must authorize MDOC to perform a criminal history check and, for employment purposes, allow review of their motor vehicle operator license record. The form includes checkboxes for different categories of personnel (contractor, volunteer, etc.) and requires the individual to indicate whether they will be entering a secure MDOC facility. The form is part of MDOC's standard screening process to ensure safety and security within their facilities.
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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 - EM Room & Control Ctr Renovation File # 472/24428.SAA
File details come from the government source that posted it. Updated .