LEIN Request 25040.pdf
PDF 165 KB Posted
- Solicitation number
- RFQ 171 260000000303 1
- Issued by
- Huron County, Michigan
About this file
This is a Criminal History Check Request Form (LEIN Request CAJ-1037) from the Michigan Department of Corrections related to the Handlon Correctional Facility Kosher Kitchen Remodel project (File #472/25040.JGH). The form is used to initiate a criminal history check through the Michigan Law Enforcement Information Network (LEIN) for individuals seeking authorization to enter the secure perimeter or property of an MDOC facility. The form collects personal identifying information including the applicant's full name, date of birth, address, sex, race, and either a driver's license number or state identification number. Applicants must indicate whether they are entering as HR personnel, a contractor, visitor, volunteer, or other designated category and whether they will be accessing the secure perimeter of the facility.
The form serves as authorization for the MDOC to conduct a comprehensive criminal history check to determine eligibility for facility access. For MDOC employment and human resources purposes, the form also permits verification of the applicant's motor vehicle operator license record to assess authorization for operating vehicles during departmental business. The requesting official or LEIN processor completes the form by documenting the applicant's signature, date of submission, and clearance status (approved or not approved). The form includes optional fields for MDOC HR to document the number of convictions and additional comments relevant to the eligibility determination.
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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: Handlon C.F. - Kosher Kitchen Remodel File # 472/25040.JGH
File details come from the government source that posted it. Updated .