LEIN Request 25140.pdf
PDF 160 KB Posted
- Attached to
- 472/25140. ABG; Kinross CF - PPD System Upgrade
- Solicitation number
- RFP-171-250000001702-4
- 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 criminal history checks for individuals seeking to enter secure MDOC facility perimeters or property. The form is specifically associated with the KCF - PPD System Upgrade project (File # 472/25140.ABG) and is used to collect personal identification details necessary for background screening, including driver's license or state ID number, date of birth, race, and sex.
The form authorizes MDOC to perform a comprehensive criminal history check and, for employment purposes, to review the individual's motor vehicle operator license record. The form is structured to capture information for various categories of personnel, including contractors, volunteers, and visitors, with a checkbox to indicate whether the individual will be entering a secure MDOC facility. The completed form will be used to determine an individual's eligibility to work, visit, or interact with MDOC offenders, with a final section for MDOC personnel to record LEIN check results and number of convictions.
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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: KCF - PPD System Upgrade File # 472/25140.ABG
File details come from the government source that posted it. Updated .