LEIN Request 25324.pdf
PDF 123 KB Posted
- Solicitation number
- RFQ 171 250000000561 2
- Issued by
- Chippewa County, Michigan
About this file
This is a LEIN (Law Enforcement Information Network) Request form from the Michigan Department of Corrections (MDOC) used to conduct criminal history checks for individuals requiring access to MDOC facilities. The form is associated with the Chippewa Powerplant Steam Surge Tank Replacement project (File #472/25324.ABG). The document is designed to collect personal information including name, date of birth, address, sex, and race, along with driver's license or state identification details from employment personnel, human resources staff, contractors, visitors, volunteers, or agency representatives who need to enter the secure perimeter or property of an MDOC facility to perform work, conduct visits, meet with staff, or work with offenders.
The LEIN request form requires individuals to authorize the MDOC to conduct a criminal history check as a prerequisite for facility access approval. For MDOC employment or human resources purposes, the form additionally authorizes a check of the applicant's motor vehicle operator license record to determine eligibility to operate a vehicle while conducting Department business. The form includes fields for MDOC personnel to document completion of the LEIN check, clearance status, and any conviction records or relevant comments. This administrative form is a standard security screening requirement rather than a procurement document with pricing, set-asides, or contract terms.
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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: Chippewa - Powerplant Steam Surge Tank Replacement File # 472/25324.ABG
File details come from the government source that posted it. Updated .