Graduate School
A leave of absence is available if you are completing coursework (excluding thesis, project, and capstone
courses) and plan to be inactive for a period not to exceed a full calendar year. Submission of this form
provides a means for the Graduate School to track your progress and to term activate you after your period
of absence, so you may register for the upcoming semester.
If you have begun the final requirement and have an in-progress grade (“X”) you may apply for a leave of
absence only in the case of extenuating circumstances. In such cases, a letter to the Associate Vice President
of the Graduate School must accompany this form explaining the circumstances; this type of leave will be
approved for one semester at a time.
Date / /
Month Day Year
Minot State ID# Graduate Program
Legal Name:
Last First Middle Former (if applicable)
Mailing Address:
Street Apt# City State Zip Code
Email: Telephone:
You are encouraged to use your Minot State email
Indicate the term(s) you are requesting leave of absence: Fall (yr.) Spring (yr.) Summer (yr.)
Reason for leave:
Student signature (required) I certify that all statements in this application are completed and true:
Signature Date
After receiving Program Director approval, submit to:
Minot Sate Graduate School Program Director signature
Fax: 701-858-4286
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