Leave of Absence Request Form
The University of Southern Mississippi
Graduate School
118 College Drive #5024 Hattiesburg MS 39406
This form is a fillable PDF. Handwritten forms will not be accepted. Please submit completed form via email.
Graduate students who experience circumstances that prevent them from maintaining active status through continuous enrollment
must request leave via this form after consulting with their graduate coordinator, advisor(s), International Students & Scholars
Services (ISSS) Office (international students only) and the Graduate School to determine if a leave of absence is appropriate.
Student Name (First, Middle, Last): Student ID:
Email:
School: Degree:
Proposed Term & Year of Leave: Proposed Term & Year of Return from Leave (1 year max):
Graduate assistants should see the "Leave of Absence Without Pay" policy in the Employee
Handbooks for information on health insurance, benefits, and reinstatement.
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):
Signatures
Student: Date:
Advisor: Date:
Date:
Date:
Graduate Director/Coordinator:
School Director:
International Student & Scholar
Services Office (international
students only):
Date:
For Graduate School Use Only
Approve Do Not Approve
Dean of Graduate School Signature:
Are you currently a Graduate Assistant?
Updated August 2019
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click to sign
signature
click to edit
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click to sign
signature
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