LEIN Request 26319.pdf
PDF 173 KB Posted
- Attached to
- 472/26319. SMD; Handlon C. F. Unit B Conversion
- Solicitation number
- RFQ 171 260000000443 2
- Issued by
- Huron County, Michigan
About this file
This is a LEIN (Law Enforcement Information Network) Request Form CAJ-1037 (Revised 09/19) issued by the Michigan Department of Corrections (MDOC) for criminal history background check purposes. The form is associated with the Handlon Correctional Facility Unit B Conversion project, File #472/26319.SMD. The document is a standardized intake form designed to collect personal identification information necessary to conduct a criminal history check for individuals seeking to enter the secure perimeter or property of an MDOC facility. The form applies to employment applicants, contractors, visitors, volunteers, and agency representatives and requires collection of the subject's full name, date of birth, address, sex, race, and either a driver's license number or state-issued identification number.
The LEIN request form authorizes the MDOC to conduct criminal history checks to determine approval for facility access to perform work, conduct visits, or work with MDOC offenders. For MDOC Human Resources and employment purposes only, the form additionally authorizes a check of the subject's motor vehicle operator license record to determine eligibility to operate vehicles while conducting Department business. The form includes sections for completion and clearance status, with an optional comments field for noting the number of convictions for HR purposes. This form serves as a prerequisite screening mechanism rather than a procurement document and does not contain pricing terms, contract awards, or funding information.
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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 C.F. - Unit B Conversion File # 472/26319.SMD
File details come from the government source that posted it. Updated .