Non-Medical Leave Of Absence Request Form - Northeastern University Page 3
ADVERTISEMENT
1
2
3Non-Medical Leave of Absence
Request Form
Part I: To be completed by the student
Name: _______________________________________________________________________________________________
Middle Name
Last/Family Name
First/Given Name
Northeastern ID: ____________________________
Degree/Major: ___________________________________________
Leave of Absence requested for:
Fall Semester/Quarter 20__
Winter Quarter (CPS only) 20__
Spring Semester/Quarter 20__
Summer Semester/Quarter 20__
Dates for Leave of Absence: From ________ /________ /___________ to ________ /________ /___________
Month
Date
Year
Month
Date
Year
Travel Information:
Date of departure from the U.S.: ________ /________ /___________
Month
Date
Year
Expected return date: ________ /________ /___________
Month
Date
Year
Contact information while on leave of absence:
Address: ____________________________________________________________________________________________
____________________________________________________________________________________________________
Phone Number: _____________________________________
Email: ______________________________________
Emergency Contact in the U.S.: ___________________________________________________________________________
Name
_____________________________________________________________________________________________________
Phone Number
Email
I certify that I am aware that my current SEVIS record will be terminated and that in order to return to the U.S. to resume my studies,
I must follow the attached instructions. The process for obtaining a new initial I-20 or reactivation of my SEVIS status should be
initiated by me by contacting the OGS as outlined in the instructions prior to my expected return date or visa interview appointment if
my current F-1 visa stamp will be expired at the time of my planned re-entry to the U.S. Additionally, I understand that I must remain
outside of the U.S. for the duration of my leave of absence and that in accordance with U.S. government regulations I may not return
to the U.S. earlier than 30 days prior to the start date of my next academic term. Furthermore, I understand that this form is solely for
the purpose of notifying the OGS of my leave of absence for SEVIS purposes. In order to be considered on an official leave of absence
by the university, I must complete any additional forms required by my college/graduate school and by the Office of the Registrar. I
should consult with my college/graduate school to ensure that I have completed all required forms for the university to officially
record my leave of absence. Additionally, I understand that there is no guarantee that my SEVIS record will be reactivated by SEVIS or
that I will be able to obtain a new F-1 visa if I am issued an initial I-20 and need a new visa for my return.
Student’s Signature: ______________________________________________________
Date: _____________________
Part II: To be completed by the SEVIS contact
I certify that the above named student has been approved for a leave of absence for the ____FL ___WN ____SP___SM term
20______ and that the student is academically eligible to resume studies for the ____ Fall/Semester/Quarter _______ Winter
Quarter (CPS only) _________ Spring Semester/Quarter _________Summer Semester/Quarter 20_________.
The last day of class attended by this student was: ________ /________ /___________
Month
Date
Year
Signature of Designated College/SEVIS Contact: ____________________________________________________________
Name/Title: ______________________________________________________
Date: ___________________________
Office of Global Services, 405 Ell Hall, 360 Huntington Ave, Boston, MA 02115
northeastern.edu/ogs | ogs@northeastern.edu | (p) 617.373.2310 | (f) 617.373.8788
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business