LEIN Request 472-24055.DPL.pdf
PDF 173 KB Posted
- Solicitation number
- RFQ 171 260000000466 2
- Issued by
- Kent County, Michigan
About this file
This document is a Michigan Department of Corrections (MDOC) Criminal History Check Request Form (CAJ-1037) associated with contract opportunity 472/24055.DPL for the Gus Harrison Correctional Facility's Replace Smoke Purge System project. The form is used to conduct background clearance for individuals requiring access to secure perimeters or properties of MDOC facilities for work, visits, meetings, or interactions with offenders. The request requires submission of personal information including full name, address, date of birth, sex, and race, along with a valid driver's license number or state identification card number issued by any state. Individuals must authorize MDOC to conduct a criminal history check through the Michigan Law Enforcement Information Network (LEIN) to gain approval for secure facility access.
The form includes optional authorization for MDOC to review motor vehicle operator license records for employees and human resources purposes. Completed LEIN requests are reviewed and marked as cleared or not cleared, with a notation field for indicating the number of convictions and optional comments. This background check process is a standard requirement for all personnel, contractors, and visitors seeking access to MDOC facilities and represents a prerequisite step in the contracting and vendor approval process for the smoke purge system replacement project at Gus Harrison Correctional Facility.
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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 .