LEIN Request 26230.pdf
PDF 159 KB Posted
- Solicitation number
- RFQ 171 260000000378 2
- Issued by
- Macomb 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 clearance related to the Macomb Correctional Facility - Housing Units 4 & 5 Level IV Conversion project (File #472/26230.MNB). The form is used to conduct background checks for individuals seeking access to the secure perimeter or property of MDOC facilities to perform work, visit, meet with, or work with MDOC offenders. The form requires personal identification information including driver's license or state ID number, date of birth, race, and sex. Requesters must indicate their relationship to the agency, such as employment, contractor, visitor, volunteer, or other representative capacity. The authorization permits MDOC to conduct a criminal history check and, for HR/Employment purposes only, to review motor vehicle operator license records for those operating vehicles during Department business.
The form includes signature and date fields for the individual being cleared and space for MDOC personnel to complete the LEIN check and indicate approval status. HR/Employment sections allow for notation of conviction counts and optional comments. This standard clearance document is a prerequisite requirement for any personnel or contractors involved in the Macomb Correctional Facility conversion project who require access to secure facility areas.
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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: Macomb Correctional Facility - Housing Units 4 & 5 Level IV Conversion
File # 472/26230.MNB
File details come from the government source that posted it. Updated .