LEIN Request 472-23129.KMM.pdf
PDF 174 KB Posted
- Solicitation number
- RFQ 171 270000000015 3
- Issued by
- Kent County, Michigan
About this file
This is a LEIN (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 designed to collect personal information and authorize criminal history background checks for individuals requiring access to the secure perimeter or property of Michigan Department of Corrections facilities. The form applies to employment candidates, contractors, visitors, volunteers, and other personnel who need approval to enter MDOC facilities to perform work, conduct visits, meet with staff, or work with offenders. Requesters must provide identifying information including driver's license or state identification number, date of birth, race, sex, and complete address details to facilitate the background check process.
The form includes authorization provisions allowing the MDOC to conduct criminal history checks and, for employment and human resources purposes, to review motor vehicle operator license records to determine eligibility for operating vehicles during department business. Upon completion of the background check, MDOC personnel must indicate clearance status and document any conviction information as applicable. The form requires signatures from both the individual being screened and the LEIN completing official, along with corresponding dates to establish official documentation of the authorization and clearance process.
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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 .