GSOM Leave of Absence or Withdrawal Request
Name: Clark ID:
Personal Email Address:
Work Telephone Number:
I would like to request a leave of absence for semester(s), and am planning to return for
the semester. I understand that this request must be approved by the Graduate School of
Management. I wish to take a leave of absence for the following reasons:
I would like to withdraw from GSOM and my program for the following reason(s):
*By typing my name, I recognize that this is equivalent to a written signature and I attest to the fact that the
information on this form is correct.
I have been awarded a U.S. federal loan. I understand that it is my responsibility to notify the
Office of Financial Assistance of my leave of absence or withdrawal.
If you are an international student, you must also have approval from the International
Students and Scholars Office, as demonstrated by a signature below.
Approved by: _______________________________________ Date: __________________
Name (please print): _________________________________
Please return this form to your academic advisor in person or by email through your Clark University