LEIN Request REV 09-2019 (with project header) - Lakeland CF.pdf
PDF 136 KB Posted
- Solicitation number
- RFQ-171-250000000552-3
- Issued by
- Barry County, Michigan
About this file
This document is a Michigan Department of Corrections (MDOC) Law Enforcement Information Network (LEIN) Request form (CAJ-1037), specifically for the Lakeland Correctional Facility's Statewide Perimeter Fence Repair/Replacement project (File #472/24052.JGH). The form is designed to conduct criminal history checks for individuals seeking to enter secure MDOC facility perimeters, including contractors, visitors, volunteers, and other personnel. The form requires detailed personal identification information such as name, address, date of birth, race, sex, and either a driver's license or state ID number.
The form authorizes MDOC to perform comprehensive background checks, including criminal history verification and, for employment purposes, motor vehicle operator license record checks. The individual completing the form must provide consent by signature, acknowledging that the information will be used to determine their eligibility to enter MDOC facilities, perform work, visit, or interact with offenders. The form includes sections for MDOC personnel to record LEIN check results, including whether the check was cleared and the number of convictions, if applicable.
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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: MDOC Statewide Perimeter Fence Repair/Replacement - Lakeland Correctional Facility File # 472/24052.JGH
File details come from the government source that posted it. Updated .