LEIN Request Form.pdf
PDF 24 KB Posted
- Solicitation number
- RFQ 171 190000000155 2
- Issued by
- Saginaw County, Flint City, Michigan
About this file
This is a LEIN (Law Enforcement Information Network) Request Form from the Michigan Department of Corrections (MDOC) used to conduct criminal history checks for vendors and contractors requiring access to MDOC facilities. The form is specific to the Saginaw Correctional Facility Propane Plant Replace/Repair project (File #472/17438.TYC) and establishes the requirements for background clearance prior to any vendor or contractor visitation or meetings with confined individuals at Michigan Department of Corrections facilities.
The form requires vendors and contractors to provide personal identification information including driver's license or state identification card number, date of birth, race, and sex to facilitate the criminal history check through LEIN. Individuals must authorize MDOC to conduct the background check as a prerequisite for facility access. The form includes staff use sections for documenting the reason for the LEIN check, the staff member requesting it, and verification of clearance status, with instructions directing individuals to www.michigan.gov/ichat for obtaining copies of their Michigan criminal history records, which involves a processing fee.
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Text version
MICHIGAN DEPARTMENT OF CORRECTIONS
VENDOR/CONTRACTOR LEIN REQUEST
CAJ-1037
REV. 04/18
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 is needed to complete this LEIN. Also needed are your date-of-birth, race and sex. Potential entry into MDOC facilities require that this LEIN check be completed and cleared.
Profession Vendor Contractor
Last Name (Please Print) 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 Michigan Department of Corrections to conduct a criminal history check, so that I may be approved to visit/meet with persons confined in a Michigan Department of Corrections facility.
Signature Date
Staff Use Only
Reason for LEIN Check
Staff requesting LEIN Check
LEIN Checked by
LEIN Clear Yes No, You may obtain a copy of your Michigan criminal history at www.michigan.gov/ichat. There is a fee for this service.
LEIN Check completed by Initials Date http://www.michigan.gov/ichat hallt2 Text Box Facility/Project Name: Saginaw Correctional Facility, Propane Plant Replace/ Repair File # 472/17438.TYC
File details come from the government source that posted it. Updated .