LEIN Request 26319.pdf
PDF 160 KB Posted
- Solicitation number
- RFP 171 260000002154 1
- Issued by
- Huron County, Michigan
About this file
This is a LEIN (Law Enforcement Information Network) Request Form CAJ-1037 from the Michigan Department of Corrections (MDOC) related to the Handlon Correctional Facility Housing Unit B Conversion project (File #472/26319.SMD). The form is designed to collect personal information and authorization for criminal history checks for individuals requiring access to the secure perimeter or property of an MDOC facility. The form requires submission of the applicant's personal identifying information, including name, address, date of birth, sex, race, and driver's license or state identification number. Applicants must authorize MDOC to conduct a criminal history check through LEIN to determine eligibility to enter secure facility areas for work-related purposes, including contractors, visitors, volunteers, and HR personnel. For MDOC employment purposes, the form also permits motor vehicle operator license record checks to determine authorization to operate vehicles during Department business.
The form includes sections for MDOC HR personnel or the requesting contractor to complete and sign, with certification of LEIN clearance status indicated as yes or no. For MDOC employment and HR purposes, the form requires documentation of any conviction history with optional comments. This administrative document serves as a prerequisite screening tool for the Housing Unit B Conversion project at Handlon Correctional Facility, ensuring that all personnel entering secure areas have completed required background clearance procedures.
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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: Handlon CF - Housing Unit B Conversion File # 472/26319.SMD
File details come from the government source that posted it. Updated .