LEIN Request 26279.pdf
PDF 1 MB Posted
- Solicitation number
- RFQ 171 270000000025 1
- Issued by
- Michigan
About this file
This is a LEIN (Law Enforcement Information Network) Request Form CAJ-1037, Revision 09/19, issued by the Michigan Department of Corrections (MDOC) for criminal history background check purposes related to the Lakeland Correctional Facility Water Softener & Salt Storage Upgrades project (File #472/26279.JLM). The form is designed to collect personal identification information from individuals requiring access to the secure perimeter or property of an MDOC facility to perform work, conduct visits, or interact with MDOC offenders. Required information includes the applicant's full name, address, date of birth, sex, race, and a valid form of identification (Driver's License or State ID number). The form requests authorization for MDOC to conduct a criminal history check through LEIN and, for MDOC HR/Employment purposes, authorization to review motor vehicle operator license records to determine eligibility to operate vehicles during Department business.
The form includes designated areas for completion by both the requesting party and MDOC personnel, with fields for the LEIN clearance status (Yes/No designation), signature lines with corresponding dates, and optional comments regarding conviction history for HR/Employment determinations. This document serves as a preliminary screening requirement for contractor and visitor access to the Lakeland Correctional Facility project and does not contain pricing, contract terms, or other procurement specifications related to the water softener and salt storage upgrade work itself.
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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: Lakeland Correctional Facility - Water Softener & Salt Storage Upgrades
File # 472/ 26279.JLM
File details come from the government source that posted it. Updated .