LEIN Request REV 09-2019 (with project header).pdf
PDF 159 KB Posted
- Solicitation number
- RFQ 171 260000000411 3
- Issued by
- Chippewa County, Michigan
About this file
This is a LEIN (Michigan 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 requiring access to secure perimeters or properties at MDOC facilities. The document requests personal identifying information including driver's license or state identification card number, date of birth, race, and sex from applicants who may be entering secure areas to perform work, conduct visits, meet with staff, or work with offenders. Applicants must authorize the MDOC to complete the criminal history check and, for employment purposes, may authorize additional checks of motor vehicle operator license records to determine eligibility to operate vehicles during Department business.
The form requires applicants to indicate their role (HR personnel, contractor, visitor, volunteer, or other), provide complete demographic and identification information, sign and date the authorization, and submit to LEIN completion and clearance by MDOC personnel. The clearance status is recorded as either approved or not approved, with an optional comment section for additional notes. This administrative screening process is a prerequisite for any individual requiring access to the Kinross Correctional Facility during the electrical upgrades project phase.
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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 .