LEIN Request Central.pdf
PDF 123 KB Posted
- Solicitation number
- RFQ 171 250000000336 2
- Issued by
- Gogebic County, Michigan
About this file
This is a criminal history background check request form issued by the Michigan Department of Corrections (MDOC) for personnel accessing secure facilities. The form, designated CAJ-1037 (Revised 09/19), is used to initiate a Law Enforcement Information Network (LEIN) criminal history check for individuals seeking entry to MDOC secure perimeters or properties. The specific project referenced is the Central Michigan Correctional Facility Wi-Fi Cabling Infrastructure project (File #472/17032.RWG). The form applies to various categories of personnel including employment or human resources staff, contractors, visitors, volunteers, and agency representatives requiring facility access.
The form requires applicants to provide personal identification information including driver's license or state identification number, date of birth, race, and sex to complete the LEIN background check. Applicants must authorize the MDOC to conduct the criminal history check and, for employment purposes, authorize motor vehicle operator license record verification for individuals who will operate vehicles during departmental business. The form includes fields for signature and date authorization, completion date by LEIN personnel, clearance determination, and for HR employment purposes, notation of conviction numbers and optional comments. No pricing, contract terms, funding sources, or set-asides are addressed in this background check request document.
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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: Central MI CF -Wi-Fi Cabling Infrastructure.
File # 472/17032.RWG
File details come from the government source that posted it. Updated .