LEIN Request 472-23129.KMM.pdf
PDF 174 KB Posted
- Solicitation number
- RFQ 171 270000000015 2
- Issued by
- Michigan
About this file
This is a LEIN (Michigan Law Enforcement Information Network) Request Form CAJ-1037 issued by the Michigan Department of Corrections for the Woodland C.F. - Site Mechanical Underground project (File #472/23129.KMM). The form is used to initiate a criminal history check for individuals requiring access to secure perimeters or properties of MDOC facilities. The document collects personal identification information including driver's license or state identification card number, date of birth, race, and sex to complete the background check process. Requesters must indicate whether they will be entering the secure perimeter/property of an MDOC facility and select their capacity, which may include HR personnel, contractors, visitors, volunteers, or agency representatives. Authorization is required from the individual for MDOC to conduct the criminal history check and, for HR/employment purposes, to check motor vehicle operator license records for individuals who may operate vehicles while conducting Department business.
The form requires completion by HR personnel or the requesting contractor and must be signed by the subject individual and dated. Upon completion, the form is reviewed by LEIN personnel who indicate clearance status and, for MDOC employment purposes, document the number of convictions and optional comments. The LEIN clearance determination is marked as either cleared or not cleared, with the latter designation not applying to human resources personnel. This form serves as a prerequisite authorization document for individuals seeking to access MDOC facilities in connection with the Woodland C.F. Site Mechanical Underground 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: Woodland C.F. - Site Mechanical Underground
File # 472/23129.KMM
File details come from the government source that posted it. Updated .