LEIN Request 26319.pdf
PDF 160 KB Posted
- Solicitation number
- RFP 171 260000002154 3
- Issued by
- Huron County, Michigan
About this file
This is a LEIN (Law Enforcement Information Network) Request form issued by the Michigan Department of Corrections (MDOC) for criminal history background check purposes. The form is associated with the Handlon Correctional Facility (CF) Housing Unit B Conversion project (File #472/26319.SMD). The document serves as the standard request template used by MDOC to conduct criminal history checks for individuals requiring access to secure perimeters or properties of MDOC facilities, including employment candidates, contractors, visitors, and volunteers who will perform work, visit, or interact with MDOC offenders.
The form requires submission of personal identifying information including driver's license or state identification number, date of birth, race, and sex to complete the LEIN background check. Requestors must authorize MDOC to conduct the criminal history check and, for employment purposes, authorize verification of motor vehicle operator license records for those who will operate vehicles during Department business. The completed LEIN form must be reviewed and cleared before an individual receives approval to enter secure facility areas. For MDOC HR and employment purposes, the form includes fields to document the number of convictions and optional comments regarding the background check results.
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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 .