LEIN Request 25139.pdf
PDF 160 KB Posted
- Solicitation number
- RFP-171-250000001703-4
- Issued by
- Chippewa County, Michigan
About this file
This document is a LEIN (Law Enforcement Information Network) Request form from the Michigan Department of Corrections (MDOC), designed to conduct a criminal history check for individuals seeking to enter a secure corrections facility or interact with offenders. The specific form is associated with the KCF - PA Upgrade project (File # 472/25139.ABG), and requires detailed personal identification information including driver's license or state ID number, date of birth, race, sex, and consent for a comprehensive background screening.
The form authorizes MDOC to perform a criminal history check and, for employment purposes, review the individual's motor vehicle operator license record. The document is a standardized template that can be used by various personnel types including contractors, visitors, volunteers, and HR personnel. The form provides checkboxes to indicate the individual's status and whether they will be entering a secure MDOC facility, with sections for both the applicant to complete personal details and for MDOC staff to record the results of the LEIN check, including noting the number of convictions if applicable.
View the file
Other files
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
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: KCF - PA Upgrade File # 472/25139.ABG
File details come from the government source that posted it. Updated .