The University Of Chicago Change Of Status Form
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1
2THE UNIVERSITY OF CHICAGO
CHANGE OF STATUS FORM
(Please check one. See the reverse side for instructions and conditions.)
Name
First
Middle
Last
Mailing Address
Telephone
Division/School
Department/Program
___ I am applying for pro-forma registration from ________ Quarter 20___ to _______ Quarter 20___.
___ I am petitioning to be granted a Leave of Absence from Scholastic Residence Status from ________
Quarter 20___ to ________ Quarter 20____.
___ I wish to withdraw from the PhD program. I entered ________ Quarter 20 ___. Effective date of
withdrawal ________ Quarter 20___.
Note: In order to better understand and meet students’ needs and concerns, please let us know of the
reason(s) for your decision by filling out the space below. Any statement you make will be strictly
confidential. We appreciate your help in this matter and wish you all the best in your future career.
Reason for Withdrawal or Leave of Absence:
I UNDERSTAND AND ACCEPT THE CONDITIONS FOR MY REQUESTED CHANGE OF STATUS AS
DESCRIBED ON THE REVERSE SIDE OF THIS FORM, AND I AGREE TO KEEP MY DEAN OF STUDENTS
INFORMED OF ANY CHANGES IN MY ADDRESS OR STATUS.
Signature
Date
___________________ Recommended
_________________
Not Recommended
Signature
Date
Chairman
Signature
Date
Area Dean of Students
Signature
Date
Graduate Affairs
OFFICE USE: ID-NO __________________________ STATUS ____________________
Copies: Student and Area Dean of Students
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