A LEAVE OF ABSENCE, which permits a student to return without penalty, is granted only to matriculated students with accumulative grade
point of 2.00 or higher. A leave may cover only one semester with privilege of renewal for one more regular semester.
INSTRUCTIONS: Please provide the information requested below, obtain the appropriate signatures required, and return the form to the
Enrollment Services front desk (Office 203) or by e-mail at email@example.com . Students applying for a leave of absence cannot be register
in any courses or have any outstanding balances with the university.
Academic Advisor: _____________________________________
Are you receiving Financial Aid from a Canadian Provincial financial aid program, or a financial aid program in the United States? YES NO
For the reason stated below, I intend to: Take a leave of Absence Effective Date: ________________Expected date of Return:_______________
*You must state a reason or this form will not be approved
Medical: Appropriate physician’s statement must be submitted to the Director of Enrollment Service
Transfer - Name of New Institution:
I understand that I am responsible for my outstanding financial obligations for the University. I understand that if I am receiving
financial aid through a government program, my financial aid may be affected by a leave of absence and that it is my responsibility to
contact the appropriate agencies to notify them of my status.
Student’s Signature: Date:
Academic Advisor Date
Director of Student Services Date
Director of Enrollment Services Date
TO BE COMPLETED BY ENROLLMENT SERVICES OFFICE
Student Services Notified
*Copies: Academic Advisor and Student Services.
FDU V-Request for Leave of Absence – Jan 2019
Request for Leave of Absence
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