LEIN Request 25278.pdf
PDF 174 KB Posted
- Attached to
- 472/25278. RWG; Ionia C. F. - IT Room Expansion
- Solicitation number
- RFQ 171 270000000032 1
- Issued by
- Michigan
About this file
This is a LEIN (Michigan Law Enforcement Information Network) Request Form CAJ-1037, revision 09/19, issued by the Michigan Department of Corrections for the Ionia Correctional Facility IT Room Expansion project (File #472/25278.RWG). The form is used to conduct criminal history checks for individuals requiring access to the secure perimeter or property of an MDOC facility to perform work, visit, or meet with MDOC offenders. The document requests personal identification information including the applicant's last name, first name, middle name, address, date of birth, sex, race, and a valid driver's license number or state identification card number. Applicants must authorize the MDOC to conduct the criminal history check and, for MDOC employment or human resources purposes, authorize a motor vehicle operator license record check to determine eligibility to operate vehicles while conducting Department business.
The form requires completion by HR personnel or authorized personnel representing the requesting contractor or agency and must be signed and dated by the applicant. Upon completion, the form is reviewed and marked as cleared or not cleared by MDOC personnel, with a field to indicate the number of convictions and optional comments for MDOC HR purposes. This document serves as a prerequisite screening requirement rather than a procurement specification or contract award document.
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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: Ionia C.F. - IT Room Expansion
File # 472/25278.RWG
File details come from the government source that posted it. Updated .