LEIN Request REV 09-2019 (with project header).pdf
PDF 159 KB Posted
- Solicitation number
- RFQ 171 260000000411 1
- Issued by
- Michigan
About this file
This is a LEIN Request form (REV 09-2019) issued by the Michigan Department of Corrections for use in conducting criminal history checks through the Michigan Law Enforcement Information Network. The form is associated with the Kinross Correctional Facility & NRT Electrical Upgrades project (File #472/26238.RWG). The LEIN Request collects personal identification information from individuals requiring access to the secure perimeter or property of MDOC facilities, including employment and human resources personnel, contractors, visitors, volunteers, and other agency representatives. Required information includes full name, date of birth, sex, race, current address, and valid identification numbers (driver's license or state ID). The form authorizes the MDOC to conduct criminal history checks to determine eligibility for entry into secure facility areas for work, visitation, or offender-related activities.
For MDOC employment and human resources purposes, the form includes provisions for motor vehicle operator license record checks to assess eligibility for operating vehicles during Department business. The completed form requires signature and date from the applicant and documentation from LEIN personnel indicating completion date and clearance status. A comments section allows notation of conviction history. This form is a standard pre-access screening document used to ensure facility security and safety at MDOC locations.
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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: Kinross Correctional Facility & NRT Electrical Upgrades
File # 472/26238.RWG
File details come from the government source that posted it. Updated .