Leave of Absence Request Form
The University of Southern Mississippi
Graduate School
118 College Drive #5024 Hattiesburg MS 39406
Graduate students who experience circumstances that prevent them from maintaining active status through continuous enrollment and
who, through consultation with their graduate coordinator, advisor(s), International Students & Scholars (ISS) Office (international
students only) and the Graduate School determine if a leave of absence is appropriate, must request leave via this form.
Student Name (First, Middle, Last):
Student ID:
Proposed Term & Year of Leave: Proposed Term & Year of Return from Leave (1 year max):
Attach school agreement (on school letterhead) that is made with your graduate program that outlines the conditions of your return from
leave and any supporting documentation for your request.
Reason for Leave (use additional sheets if necessary):
Student: Date:
Graduate Director/Coordinator:
School Director:
International Student & Scholars
Office (international students only):
For Graduate School Use Only
Approve Do Not Approve
Dean of Graduate School Signature:
Are you currently a Graduate Assistant?
Graduate assistants should see the "Leave of Absence Without Pay" policy in the Employee
Handbooks for information on health insurance, benefits, and reinstatement.
This form is a fillable PDF. Handwritten copies will not be accepted.