Office of Graduate Studies
Leave of Absence Request
Please print legibly
Last Name First Name MI Student ID Number
Mailing Address Major
City / State / ZIP Telephone
Graduate (classified)
Graduate (conditionally classified)
Graduate Credential
Graduate Certificate
Type of leave (check only one) Length of Requested Leave
Military
Medical
Personal From (last term enrolled):
*
Department approval
required. See below.
Educational *
To (Year & Term to Return):
Reason for request: This statement must be consistent with University Policy.
Attach verification of all conditions as necessary. Without a clear, concise statement and documentation
no action will be taken on your request:
I have read and understand the instructions and policies regarding a Leave of Absence, including my obligation to
file an application for re-admission during the initial filing period and pay the applicable fees, if I am out two or more
semesters.
Student Signature:
Date:
* For Educational Leaves ONLY - Department recommendation required for educational leave
Departmental Recommendation:
Yes
No
Faculty Advisor / Chair Signature:
Date:
Graduate Coordinator Signature:
Date:
RETURN COMPLETED FORM TO THE OFFICE OF GRADUATE STUDIES - RFC 206
FOR OFFICE USE ONLY
APPROVED
DENIED
By:
Date:
Comments:
Date Posted:
Updated 10/2009
