Fillable Graduate Request for Leave of Absence/Withdrawal/Readmit (Stevens Institute of Technology)

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Graduate Request for Leave of Absence/Withdrawal/Readmit (Stevens Institute of Technology)

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Country of origin: US
File type: PDF

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February 26, 2019, Leave_of_Absence.doc
Stevens Institute of Technology
Castle Point on Hudson
Hoboken, NJ 07030-5991
201.216.5555
FAX 201.216.8030
Office of the Registrar
registrar@stevens.edu
http://www.stevens.edu/registrar
Graduate Request for Leave of Absence/Withdrawal/Readmit
Note: Submitting this form will withdraw you from all of your courses if you are currently enrolled
and you will be responsible for any tuition balance
Undergraduates must contact the Office of Undergraduate Academics to Withdraw.
Name:
Student Identification No.: __________________
Address:
STREET
CITY STATE ZIP CODE
I request a Leave of Absence from* ________________ t
o ________________
DATE DATE
* Leave of Absence is granted for a maximum of two years, and must be renewed each year.
-OR-
I permanently withdraw from Stevens effective ________________
DATE
Reason(s) for Leave of Absence or Withdrawal:
Academic Standing
Family Obligatio
ns *
Availability of Course Offerings Financial
Business/Work Obligations
Medical *
Em
ployer no longer pr
ovides tuition assistance Relo
cation
Other (please explain)
*Must contact Office of Graduate Student Affairs prior to submitting form to Office of Graduate Academics
-OR-
I request to be Readmitted effective:
Term: Fall Winter Spring Summer I Summer II Year
Year: 20____
Thank You.
SIGNATURE DATE
ADVISOR DATE
DEPARTMENT DIRECTOR DATE
DIRECTOR OF GRADUATE STUDENT AFFAIRS (If reason is Family Obligation or Medical) DATE
OFFICE OF GRADUATE ACADEMICS DATE
Expected Semester of Return
________________
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Graduate Request for Leave of AbsenceWithdrawalReadmit (Stevens Institute of Technology)

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Completed 27 August 2020

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