Leave of Absence (LOA) Request Form

Leave of Absence (LOA) Request Form
Current Campus*
Student Services Email
Name*

First NameMiddle NameLast Name
Student ID*
Program *
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Student Status?*
The reason for my request is:*
Other. Explain:*
I request a leave of absence from
I will return on
Guidelines:
- Students in good financial and academic standing who find it necessary to interrupt their education may apply for a Leave of Absence (LOA) for up to one semester (two consecutive eight-week sessions) per calendar year.
- Application for LOA must be made prior to the start of the session in which the LOA is to begin. The LOA will NOT be granted for a session that has already started. Students cannot apply for Leave of Absence in the middle of their semester.
- Failure to return at the end of an approved LOA will result in a student’s being withdrawn from the university.
- International students are eligible for LOA after they have successfully completed 12 credits or two semesters (four consecutive terms of 8-weeks).
- A leave of absence does not adversely affect satisfactory progress toward a degree. Contact Financial Aid for information on the effects of a Leave of Absence on financial aid packages.
By checking the boxes below:*

I understand that if I have Stafford loans and do not return from a leave, my loans may go into immediate repayment.I understand the Leave of Absence (LOA) guidelines mentioned above in accordance to the Academic Catalog.
***Online students must submit this form to Student and Retention Services***
Student Signature*

Clear
Date:*

MonthDayYear
Office Use Only

Printed Name/Signature

Student Services*: _________________________________ [ ] Approved [ ] Denied

Student Finance: __________________________________ [ ] Approved [ ] Denied

DSO (If applicable): _______________________________ [ ] Approved [ ] Denied

Registrar: ________________________________________ [ ] Approved [ ] Denied

GPA: _________

Comments:________________________________________
Should be Empty: