LEIN Request REV 09-2019 (with project header) - Newberry CF.pdf
PDF 130 KB Posted
- Solicitation number
- RFQ-171-250000000171-2
- Issued by
- Livingston County, Michigan
About this file
This document is a Law Enforcement Information Network (LEIN) Request form (CAJ-1037) from the Michigan Department of Corrections (MDOC) associated with the MDOC Statewide Perimeter Repair/Replacement project at Newberry Correctional Facility (File #472/24052.JGH). The form is used to conduct criminal history checks for individuals who need to enter MDOC facilities, whether as employees, contractors, visitors, or volunteers.
The form requires personal identification information including name, address, date of birth, sex, race, and either a driver's license number or state ID number. It includes an authorization section for MDOC to conduct the criminal background check and, for HR/employment purposes, to check motor vehicle records. The form has sections for LEIN completion verification, clearance status, and conviction records for employment purposes. This appears to be a standard security screening document that would be required for anyone needing access to the secure perimeter of the Newberry Correctional Facility in connection with the perimeter repair/replacement project.
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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 Repair/Replacement - Newberry Correctional Facility File # 472/24052.JGH
File details come from the government source that posted it. Updated .