Fillable A LEAVE OF ABSENCE, which permits a student (Fairleigh Dickinson University)

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A LEAVE OF ABSENCE, which permits a student (Fairleigh Dickinson University)

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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 esvancouver@fdu.edu . Students applying for a leave of absence cannot be register
in any courses or have any outstanding balances with the university.
Last Name:
First Name:
Student ID:
Program Major:
Concentration:
E-mail:
Home Phone:
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
Reason(s):
Medical: Appropriate physician’s statement must be submitted to the Director of Enrollment Service
Transfer - Name of New Institution:
Financial:
Academic:
Employment:
Other:
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:
APPROVALS:
______________________________________ ___________________
Academic Advisor Date
___________________ ______________________________________
Director of Student Services Date
______________________________________ ___________________
Director of Enrollment Services Date
Comments:
TO BE COMPLETED BY ENROLLMENT SERVICES OFFICE
CGPA:
Cum. Credits:
ID Card Deactivated
Date:
Initials:
Account Balance:
Colleague Update
Date:
Initials:
Date:
Initials:
Student Services Notified
Date:
Initials:
*Copies: Academic Advisor and Student Services.
FDU V-Request for Leave of Absence – Jan 2019
ADDRESS
Street:
Province/State:
Apartment #:
Country:
City:
Postal Code:
Request for Leave of Absence
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A LEAVE OF ABSENCE, which permits a student (Fairleigh Dickinson University)

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Completed 21 August 2020

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