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

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

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

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  • 12 check-boxes
  • 29 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: September 12, 2018
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.
Graduate Standing: Conditionally Classified □ Credential □ Classified □ GPA □
Circle term and enter year (Minimum of 1 term, maximum of 1 year.):
Leave to begin: Fall / Spring _____________ Plan to Return: Fall / Spring ____________
Year Year
Anticipated Graduation Date: Fall / Spring ____________
Year
Is this an extension of an approved Planned Educational Leave? Yes / No (Circle)
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? Yes / No (Circle)
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
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GRADUATE REQUEST FOR PLANNED EDUCATIONAL LEAVE (California State University, Dominguez Hills)

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Completed 18 August 2020

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