LEIN Request REV 09-2019 (with project header).pdf
PDF 159 KB Posted
- Solicitation number
- RFQ 171 260000000411 2
- Issued by
- Michigan
About this file
This is a LEIN (Law Enforcement Information Network) Request Form issued by the Michigan Department of Corrections for the Kinross Correctional Facility & NRT Electrical Upgrades project (File #472/26238.RWG). The form is used to conduct criminal history checks for individuals seeking access to the secure perimeter or property of Michigan Department of Corrections facilities. Authorized requestors include employment and human resources personnel, contractors, visitors, volunteers, and other agency representatives who require approval to enter MDOC facilities to perform work, visit, meet with, or work with MDOC offenders.
The form requires applicants to provide personal identification information including full name, date of birth, address, sex, and race, along with a valid driver's license number or state identification number. Applicants must authorize the MDOC to conduct the criminal history check and, for employment purposes, authorize a motor vehicle operator license record check if the individual will operate a vehicle while conducting Department business. The form includes fields for MDOC HR/Employment personnel to document the number of convictions and provide optional comments, and requires signature and date from both the applicant and the LEIN completing official, with a final clearance determination of yes or no.
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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 .