LEIN Request 25362.pdf
PDF 165 KB Posted
- Solicitation number
- RFQ 171 260000000155 4
- Issued by
- Gogebic County, Michigan
About this file
This is a LEIN (Law Enforcement Information Network) Request form issued by the Michigan Department of Corrections for criminal history background check purposes. The form is associated with the Central Michigan Correctional Facility HVAC Improvements Phase 1 project (File #472/25362.CTS). The document is a standardized form (CAJ-1037, Rev. 09/19) used to collect personal identification information from individuals requiring access to the secure perimeter or property of MDOC facilities. The form requests demographic data including driver's license or state identification number, date of birth, race, and sex, along with authorization for MDOC to conduct criminal history checks on individuals entering secure facility areas to perform work, visit, or interact with offenders.
The LEIN request form serves as a prerequisite screening tool for the HVAC improvements project at Central Michigan Correctional Facility. Individuals classified as HR personnel, contractors, visitors, volunteers, or other agency representatives must complete this form to obtain clearance for facility access. The form includes a signature line authorizing the MDOC to conduct background checks and, for HR/employment purposes only, to review motor vehicle operator license records to determine eligibility to operate vehicles during Department business. The completed form is reviewed and cleared by MDOC personnel, with space provided for noting conviction information and optional comments relevant to clearance 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: Central Michigan C.F. – HVAC Improvements Phase 1 Project File # 472/25362.CTS
File details come from the government source that posted it. Updated .