Leave Of Absence Petition - California State University Page 3

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Office of the University Registrar
UNDERGRADUATE/2
BA
nd
LEAVE OF ABSENCE PETITION
Last Name
First Name
M.I.
Student ID Number (NOT SSN)
Street Address
Apt #
Telephone Number
City
State
Zip
Major
Undergraduate
2
Bachelors
nd
Email
TYPE OF LEAVE
LENGTH OF REQUESTED LEAVE
Medical
Educational*
Last Term Enrolled
Year and Term of Return
Military
Personal
This statement must be consistent with the University’s Leave of Absence policy as stated on
*Department recommendation required (see below)
the cover sheet. Attach verification of all conditions as necessary. Please provide a clear, concise statement.
REASON FOR REQUEST:
I have read and understand the instructions and policies regarding a Leave of Absence.
Student Signature ___________________________________________________________________
Date _________________________
Department Recommendation
YES
NO
FOR EDUCATIONAL LEAVES ONLY
Faculty Advisor or Dept. Chair Signature ____________________________________________
Date _________________________
RETURN COMPLETED AND SIGNED FORM TO THE OFFICE OF THE UNIVERSITY REGISTRAR, LASSEN 2000
APPROVED
DENIED
By _____________________________________________________
Date _____________________________
FOR OFFICE USE ONLY
Comments _______________________________________________________________________________________
Date Posted _____________________________
_______________________________________________________________________________________
Updated 12/11/13

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