LEIN Request REV 09-2019 (with project header) - St. Louis CF.pdf
PDF 136 KB Posted
- Solicitation number
- RFQ-171-250000000555-1
- Issued by
- Gogebic County, Michigan
About this file
The document is a Law Enforcement Information Network (LEIN) Request form from the Michigan Department of Corrections (MDOC), specifically associated with the Statewide Perimeter Fence Repair/Replacement project at St. Louis Correctional Facility (File # 472/24052.JGH). This form is designed to facilitate a criminal history check for individuals seeking to enter a secure MDOC facility, whether as an employee, contractor, volunteer, or visitor. The form requires detailed personal identification information, including driver's license or state ID number, date of birth, race, and sex, to complete the background screening process.
The LEIN Request authorizes MDOC to conduct a comprehensive criminal history check and, for employment purposes, review the individual's motor vehicle operator license record. The form includes checkboxes to indicate the purpose of entry (contractor, visitor, volunteer, etc.) and whether the person will be entering the secure perimeter of a corrections facility. The bottom of the form is reserved for MDOC personnel to record the LEIN check results, including whether the check is cleared and the number of convictions, if applicable. This standardized form ensures a systematic approach to vetting individuals who may interact with MDOC facilities and offenders.
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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 - St. Louis Correctional Facility File # 472/24052.JGH
File details come from the government source that posted it. Updated .