LEIN Request Form.pdf
PDF 183 KB Posted
- Solicitation number
- RFQ 171 260000000232 2
- Issued by
- Saginaw County, Flint City, Michigan
About this file
This is a LEIN (Michigan Law Enforcement Information Network) Request Form issued by the Michigan Department of Corrections (MDOC) for criminal history background checks. The form is specifically designated for the Saginaw Correctional Facility (SRF) Sewer Screening Improvements project, filed under reference number 472/25355.CTS. The form applies to individuals seeking access to MDOC secure facilities and data, including employees, contractors, volunteers, and visitors. Requesters must provide personal identification information including name, date of birth, sex, race, and valid identification documentation (driver's license or state ID). The form authorizes MDOC to conduct comprehensive criminal history checks and, for employment purposes, to review motor vehicle operator license records to determine eligibility for operating vehicles on Department business.
The form includes sections for completion by HR personnel or non-HR MDOC staff, with designated spaces for recording LEIN clearance status, conviction counts, and optional comments. The authorization requires the signature and date of the individual being cleared and must be completed and reviewed by designated MDOC personnel. This clearance process is a prerequisite for any individual—whether employed directly by MDOC or as part of a contractor team—who will access the secure perimeter or work with offenders at the Saginaw Correctional Facility during the sewer screening improvements project.
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Text version
MICHIGAN DEPARTMENT OF CORRECTIONS
LEIN REQUEST
CAJ-1037.
REV. 06/24.
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).
Please provide a copy of your Driver’s License or State Identification Card. Date-of-birth, race and sex are also 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) Correctional 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 one of the following types of identification information:
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 access MDOC secure data and/or 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 HR/Employment Non-HR
MDOC Employment/HR purposes: Indicate the # of convictions:
Comment (Optional):
*Gray box for MDOC internal use only
FACILITY/PROJECT: SAGINAW CORRECTIONAL (SRF) / SEWER SCREENING IMPROVEMENTS FILE: 472/25355.CTS
| EmploymentHuman Resources: Off |
| HR Personnel Requesting: |
| Contractor: Off |
| Volunteer: Off |
| Contractor Agency: |
| Visitor: Off |
| Other: Off |
| Agency Representing: |
| Agency Representing_2: |
| Agency Representing_3: |
| undefined: Off |
| Yes: Off |
| Last Name: |
| First Name: |
| Middle Name: |
| Address 1: |
| Address 2: |
| State: |
| Zip Code: |
| Date of Birth: |
| Sex: |
| Race: |
| Drivers License: |
| State issued by: |
| State ID: |
| State issued by_2: |
| Date: |
| Yes_2: Off |
| No: Off |
| HREmployment: Off |
| NonHR: Off |
| Comment Optional: |
| Completed By: |
| Date Completed: |
File details come from the government source that posted it. Updated .