Leave of Absence Form

Leave of Absence Form
All students requesting a Leave of Absence (LOA) must complete this form after discussing their decision with the appropriate College administrator(s). If you are approved for a leave of absence, you are eligible to return without reapplication if within the approved time frame. Non-attendance does not constitute notification of intent to apply for leave of absence status.

The date of leave status is the date the Registrar receives this signed form. Complete all information requested; incomplete forms will not be accepted.
Student Information
Student's Name (Passport Name)

First NameLast Name
Address

Street Address

Unit, APT, Suit

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.

SEVIS Information
Student ID
SEVIS ID #
Your SEVIS ID is located in the upper left-hand corner of your I-20 form.
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

LOA Information
Leave of Absence Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Leave of Absence Return Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Last Day of Attendance

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Write the detailed reason for leave of absence
Signed Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
Should be Empty:

Student Information