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 is a LEIN (Law Enforcement Information Network) Request form issued by the Michigan Department of Corrections (MDOC) for criminal history background checks related to the MDOC Statewide Perimeter Repair/Replacement project at Newberry Correctional Facility (File #472/24052.JGH). The form is designed to collect personal identification information from individuals seeking access to secure perimeters or properties of MDOC facilities, including contractors, visitors, volunteers, and HR personnel. Required information includes the applicant's full name, date of birth, address, sex, race, and identification numbers (either a Driver's License or State ID number). The form authorizes MDOC to conduct criminal history checks through LEIN to determine eligibility for accessing secure facility areas for work-related purposes, visiting, meetings, or interactions with MDOC offenders.
The LEIN request form includes provisions for MDOC HR and Employment personnel to verify motor vehicle operator licenses for employees who may operate vehicles during Department business. The form requires the applicant's signature and date authorization, with completion and clearance documented by MDOC personnel. The revision date noted is 09/19 (September 2019), and the form includes fields for recording the number of convictions and optional comments. This form is a standard administrative document required prior to facility access and does not contain pricing, contract terms, or financial information.
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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 .