REQUEST FOR LEAVE OF ABSENCE UNIVERSITY OF NEW ENGLAND Name: Personal Reference Number (PRN): 910 Campus: □ Biddeford □ Portland □ External (Off Campus or Distance Ed) College: □ CAS □ WCHP □ COM □ COP □ CGS Level: □ Undergraduate □ Graduate □ Certificate or Other _________________ Program and Major: UNE Policy Regarding Leave of Absence: A Leave of Absence for a specified period of time, not to exceed one (1) academic year, may be granted to a matriculated student with the authorization of the Academic Dean, Program/School Director or designate and upon completion of the required ‘Request for Leave of Absence’ form available from your respective Program/School Director, Office of Student Affairs, or the Office of the Registrar. The effective date of Leave of Absence will be determined by the date this form is received in the appropriate Academic Dean's office. Application for readmission is not necessary if the student returns as planned; however, the student who does not return at the specified time will be administratively withdrawn and will then be subject to readmission procedures. The University’s policy on Leave of Absence Tuition Credit is found in your respective catalog. Proposed Date of Leave: Proposed Return: Reason for Leave Request: During my Leave of Absence Mail should be sent to: Street Phone City State Zip By signing below I acknowledge that advisor, department chair, continuing education, or dean’s signatures below only address considerations related to academic policy. Financial policies regarding withdrawal/LOA refunds are governed by approved policies without exception. Student Signature (required): Date: Your Request for Leave of Absence requires approval by academic and administrative authorities noted below. There are suggested contacts, also shown below, which will be helpful to you as you plan your leave.

REQUIRED SIGNATURES Program Director or Department Chair/Associate Dean of Clinical Affairs: Signature Date Student has been informed of existing conditions of Leave of Absence (attached) Yes Not applicable Academic Advisor (Undergraduate only): Signature Date _____________ Office of Student Affairs or UNECOM Office of Recruitment, Student, and Alumni Services: ID collected □ Yes □ No Signature Date Reason Code SUGGESTED CONTACTS If applicable, contact the following offices: Financial Aid (financial aid recipients only). Work Study or Campus Employer: Notify employer. Housing (Univ. Housing-contracted only). Mail Services (Turn in your mailbox key). Upon return, contact Mail Services for a new campus mailbox assignment.Student Accounts: Inform Student Accounts of any special billing instructions. Library: Return books and other materials. Dining Services: (Commuters) Arrange for refund of money applied to your declining balance account. Campus/Finley Center: Empty locker/return lock.

FINAL APPROVAL OF LEAVE REQUEST Official Effective Date of Leave of Absence: Signature: Date:

Academic Dean or Designate

As an official record of enrollment, the original of this document is made part of the permanent student record in the Office of the Registrar at the home campus. The student should pick up a completed copy from the Office of the Registrar at their home campus. If, within 10 days, you have not received a letter from your Academic Dean acknowledging receipt of your leave of absence form stating your official withdrawal date, contact the Academic Deans office immediately.