LEIN Request 472-24055.DPL.pdf
PDF 173 KB Posted
- Solicitation number
- RFQ 171 260000000466 1
- Issued by
- Michigan
About this file
This is a LEIN (Law Enforcement Information Network) Request Form CAJ-1037 issued by the Michigan Department of Corrections for a criminal history check related to contract opportunity 472/24055.DPL at Gus Harrison Correctional Facility. The form is designed to collect personal identification information from individuals requiring access to the secure perimeter or property of an MDOC facility to perform work, conduct visits, or interact with MDOC offenders. The specific project associated with this request is the replacement of the smoke purge system at Gus Harrison CF. The form requires standard identification details including driver's license or state identification number, date of birth, race, and sex to complete the criminal history background check through Michigan's law enforcement database.
The LEIN request authorization allows the MDOC to conduct a criminal history check as a prerequisite for facility access approval. For MDOC employment or human resources purposes, the form includes an additional authorization for the Department to review motor vehicle operator license records to determine eligibility to operate vehicles during departmental business. The form includes fields for documenting the number of convictions and optional comments by MDOC personnel completing the background check verification. Completion and clearance of the LEIN check are documented on the form to verify that the individual has been cleared for facility access.
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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: Replace Smoke Purge System File # 472/24055.DPL
File details come from the government source that posted it. Updated .