GSOM Leave of Absence or Withdrawal Request
Name: Clark ID:
Home Address:
Telephone Number:
Personal Email Address:
Current Employer:
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):
Signature*: Date:
*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
email account.
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