*Student Name |
|
*Social Security Number |
(999999999) |
NIU ZID Number |
|
*Email Address
|
|
*Verify Email Address |
|
*Program of Study |
|
|
I am currently working toward (degree)
Hours completed
|
|
I began degree
coursework during the
semester
Year (YYYY)
|
|
Reason for requesting leave of absence |
|
|
I request a leave of absence commencing with the |
semester
Year (YYYY)
|
|
I will re-enroll again in the |
| semester
Year (YYYY) |
By entering my name below, I affirm my understanding that during
my leave of absence I will not have access to the resources of
the university. I understand that my leave is granted only for
the period agreed to. I acknowledge that a leave of absence
exempts me from the continuous enrollment policy but not from
the limitation of time to degree.
|
Student Name Date
(MM/DD/YYYY)
|
Department decision
Approved
Not Approved |
| Grad Director
Date
(MM/DD/YYYY) |
| |
|
NOTE: *indicates required
field
|
