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 academic year.
A leave of absence does not adversely affect satisfactory progress toward a degree.
Students are encouraged to consult an academic advisor and the Student Financial Services Department before taking a leave.
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.
Failure to return at the end of an approved leave of absence results in the student being withdrawn from the University.
International students in good standing who find it necessary to interrupt their education may apply for a Leave of Absence for a maximum of one semester (two consecutive eight-week terms) once they have successfully completed two semesters (four consecutive terms of 8 weeks or 12 credits)
per academic year.
International students cannot apply for Leave of Absence in the middle of their semester.

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.

***Students must be cleared by the Student Support Services Department***

Student Signature*

Date:*

Office Use Only

Printed Name/Signature

Student Services*: _________________________________ [ ] Approved [ ] Denied

Student Finance: __________________________________ [ ] Approved [ ] Denied

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

Registrar: ________________________________________ [ ] Approved [ ] Denied

GPA: _________

Comments:________________________________________