Leave of Absence Fee Waiver*
First Name of Student Last Name of Student
Street Address
City
State
Zip Code
Contact Phone Number
Semester(s) for which you are requesting a fee waiver
Year (YYYY) Student I.D. Number
Fall
Spring
Under special circumstances, students who are approved for a Leave of Absence may request a fee waiver. The Dean of
Graduate Studies, Research, and Innovation may authorize a waiver provided the request and supporting documentation is
received before the end of the semester.
Reason for Waiver Request
**
:
Medical reasons (
please provide supporting documentation from your medical professional
)
A required course was canceled by the University or the department is not offering a course needed for degree
progression this semester (
please provide supporting documentation from the department
)
Other extenuating circumstance (
please provide supporting documentation
)
Student's Signature
Date (mm/dd/yyyy)
*Please note: Students must also fill out the Leave of Absence form in order to be reviewed
and granted the fee waiver. Leave of Absence forms are submitted to the Registrar’s ffice.
** Failure to submit supporting documentation will result in delay in processing.
Below for Graduate School Use Only
Waiver Status:
Granted: Denied:
Graduate School Official's Signature Date (mm/dd/yyyy)
Please e-mail digitally completed form to: GPSinfo@southernct.edu
Please e-mail digitally completed form to: GPSinfo@southernct.edu
click to sign
signature
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signature
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