LEIN Request REV 04-2018.pdf

PDF 30 KB Posted

Attached to
File No. 472/17042. TAP-Alger CF-Replace/Repair Propane Plant
Solicitation number
RFQ 171 180000000781 2
Issued by
Alcona County, Michigan

About this file

This is a LEIN (Law Enforcement Information Network) Request form issued by the Michigan Department of Corrections (MDOC) for vendor and contractor criminal history background checks. The form requires vendors and contractors who need access to MDOC facilities to provide personal identification information including full name, date of birth, sex, race, and a valid driver's license number or state identification card number. The completed form authorizes MDOC to conduct a criminal history check through the Michigan Law Enforcement Information Network to determine eligibility for facility entry and approval to visit or meet with confined individuals. The form includes fields for staff to document the reason for the LEIN check, the staff member requesting the check, verification of clearance status, and completion certification with initials and date.

This form serves as a mandatory prerequisite for vendor and contractor site access rather than a procurement document with pricing or contract terms. There are no pricing terms, set-asides, award dates, or contract renewal options associated with this document. The LEIN clearance process is a compliance and security requirement that must be completed before vendors or contractors are permitted to enter Michigan Department of Corrections facilities. Individuals may obtain a copy of their Michigan criminal history independently through www.michigan.gov/ichat, though a fee applies for this service.

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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: ________________________________ File # 472/_______.____

File details come from the government source that posted it. Updated .