Fillable FOR PLANNED EDUCATIONAL LEAVE GRADUATE REQUEST (California State University, Dominguez Hills)

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FOR PLANNED EDUCATIONAL LEAVE GRADUATE REQUEST (California State University, Dominguez Hills)

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The FOR PLANNED EDUCATIONAL LEAVE GRADUATE REQUEST (California State University, Dominguez Hills) form is 1 page long and contains:

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  • 12 check-boxes
  • 18 other fields

Country of origin: US
File type: PDF

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FOR OFFICE USE ONLY
PLACE DATE STAMP HERE
GRADUATE REQUEST
FOR PLANNED EDUCATIONAL LEAVE
OFFICE OF ADMISSIONS AND RECORDS (WH 290)
FOR OFFICE USE ONLY:
Graduate Studies Signature:
Good Standing
□ Yes □ No
□ Approved
□ Denied
□ Returned Unprocessed
□ Student Notified
Processed By:
Date Posted:
Last Updated: March 23, 2020
STUDENT ID:
PHONE NUMBER:
LAST NAME:
FIRST NAME:
ADDRESS:
CITY:
STATE:
ZIP CODE:
A Planned Leave must be requested prior to the beginning of the term for which the leave is to begin.
Classified □ GPA □
____________
Graduate Standing: Conditionally Classified □ Credential □
Circle term and enter year (Minimum of 1 term, maximum of 1 year.):
Leave to begin: _____________ Plan to Return:
Year
Year
Anticipated Graduation Date:
____________
Year
Is this an extension of an approved Planned Educational Leave?
Approval of the leave does not constitute an extension of the time period for the completion of all coursework and other
requirements for the Master’s degree.
Program Coordinator Approval: Approved □ Denied □
______________________________________
Program Coordinator Signature
Please explain briefly how this leave will assist in clarifying your goals or relate to your educational objectives:
Did you receive financial aid at CSUDH?
If yes, you must clear with the Financial Aid Office before your leave can be approved.
______________________________________ ______________________________________ ___________________
Financial Aid Officer’s Name Financial Aid Officer’s Signature Date
I have read the provisions of the Planned Educational Leave Policy in the University Catalog and understand that
non-compliance will result in forfeiture of the advantages of the planned leave.
_________________________________________ ______________
Student Signature Date
Please email the completed form with required signatures to admit@csudh.edu by the appropriate deadline
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FOR PLANNED EDUCATIONAL LEAVE GRADUATE REQUEST (California State University, Dominguez Hills)

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Completed 18 August 2020

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