LEIN Request 26396.pdf
PDF 129 KB Posted
- Attached to
- 472/26396. SAA; WHVCF - HVAC Repairs
- Solicitation number
- RFP 171 260000002683 3
- Issued by
- Washtenaw County, Michigan
About this file
This is a LEIN (Law Enforcement Information Network) Request Form CAJ-1037 from the Michigan Department of Corrections (MDOC) used to conduct criminal history checks for individuals requiring access to MDOC secure facilities. The form is associated with a project at the Wheatfield Valley Correctional Facility (WHVCF) involving HVAC repair work in Calhoun and Dickinson counties, referenced as File #472/26396.SAA. The document serves as an authorization mechanism for MDOC to verify criminal backgrounds and, when applicable, motor vehicle operator license records for employment purposes before granting facility access to contractors, visitors, volunteers, or other personnel who will enter secure perimeters or work with offenders.
The form requires submission of personal identification information including driver's license or state ID number, date of birth, race, and sex to complete the background check process. Contractors or other requestors must explicitly authorize the MDOC to conduct the criminal history check and, if applicable, review motor vehicle records. The completed form requires signature and date from the requestor and documentation of completion by MDOC personnel, including notation of any convictions and clearance status. This administrative document does not contain pricing, budget, term, or other contract-specific commercial terms, but rather establishes the security screening requirements prerequisite to contractor participation in the HVAC repair project.
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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: WHVCF - Calhoun & Dickinson HVAC Repair File # 472/26396.SAA
File details come from the government source that posted it. Updated .