LEIN Request 26396.pdf
PDF 129 KB Posted
- Attached to
- 472/26396. SAA; WHVCF - HVAC Repairs
- Solicitation number
- RFP 171 260000002683 4
- Issued by
- Washtenaw County, Michigan
About this file
This is a LEIN (Law Enforcement Information Network) Request Form CAJ-1037 issued by the Michigan Department of Corrections (MDOC) for criminal history background check authorization. The form is associated with a facility/project identified as WHVCF - Calhoun & Dickinson HVAC Repair (File #472/26396.SAA). The document is designed to collect personal identification information from individuals requiring access to the secure perimeter or property of an MDOC facility, including employees, contractors, visitors, and volunteers. Requestors must provide standard identification details such as driver's license or state identification card number, date of birth, race, and sex to facilitate the criminal history check required for facility access clearance.
The form authorizes the MDOC to conduct criminal background checks as a prerequisite for approval to enter secure areas and perform work, visit, or interact with MDOC offenders. For MDOC HR and employment purposes, the form may also be used to verify motor vehicle operator license records to determine eligibility to operate vehicles during Department business. The requesting entity must indicate their relationship to the agency (HR personnel, contractor, visitor, volunteer, or other), and upon completion of the LEIN check, the form documents clearance status and, where applicable, notes the number of convictions and optional comments. The form requires signatures from both the requestor and the LEIN-completing personnel, with dated entries documenting authorization and clearance approval.
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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 .