Student Petition for a Leave of Absence The Petition for a Leave of Absence The Graduate School, University…

Download Student Petition for a Leave of Absence The Petition for a Leave of Absence The Graduate School, University…

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Student Petition for a Leave of Absence The Graduate School, University of Memphis, 201 FedEx InstitutePhone: 901.678.4212 / Fax: 901.678.0378 This form is for students who must take a leave of absence within the final stage (dissertation, thesis, final project) of their degree program due to circumstances outside of their control. Appropriate documentation must be provided by the student and approved by all signatories. The student must be in good academic standing to request a leave of absence. To be completed by student: _________________________________________________________________________________ U_____________________ Students Last Name First Name Middle Name UID Number __________________________________________________________________________________________________________ Mailing Address City State Zip Code __________________________________________________________________ ____________________________________ Email Address Telephone Number _____________________________________________________ _________ Student Level: Masters Doctoral Major Overall GPA Reason for Leave: Medical Military Personal Please attach all relevant documents to this form. Acceptable documents include: Medical (Physical or Psychological): A letter from a health-care provider. Military: A copy of your military orders. Personal: A short letter explaining your circumstances, detailing the reason for the leave request as well as third party supporting documentation. Fall Spring Summer _______ (Year) Fall Spring Summer _______ (Year) _________________ Date I formally request a leave of absence for the following semester: I will resume my studies for the following semester: _________________________________________________ Student Signature To be completed by the students department: Action: Request Approved Request Denied Reason:______________________________________________________ _________________________________________ _________________________________________ ______________ Major Advisor (Please Print) Major Advisor Signature DateAction: Request Approved Request Denied Reason: _____________________________________________________ __________________________________________ _________________________________________ _______________ Department Chair Name (Please Print) Department Chair Signature Date Action: Request Approved Request Denied __________________________________________ _________________________________________ _______________ College Director of Graduate Studies (Please Print) College Director of Graduate Studies Signature Date Both the students Thesis/Dissertation Chair and the Department chair must approve this form before approved by University of Memphis administration. To be completed by The Graduate School: Action: Request Approved Request Denied Reason: _____________________________________________________ ___________________________________________ _________________________________________ ________________ Graduate School Dean/Designee (Please Print) Graduate School Dean/Designee Signature Date Students Last Name: First Name: Middle Name: Mailing Address: City: State: Zip Code: Email Address: Telephone Number: Overall GPA: Year_2: Reason_2: College Director of Graduate Studies: Reason_3: Major Advisor: Department Chair: U-Number: Student's Major: Master's: Doctoral: Medical: Military: Personal: Fall_1: Spring_1: Summer_1: Year_1: Fall_2: Spring_2: Summer_2: Reason_1: Graduate School Dean/Designee:

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