Leave of Absence Request

This form MUST be completed by the student.

Name:

SHANE DAHLQUIST

Student IRN:

I will start my temporary break on:

Start Date :

9051729853

I will return to class on or before:

1/13/2015

Return Date:

1/20/2015

If you are submitting your Leave of Absence Request after being out of attendance for longer than 14
days, explain why you were unable to submit your request for a temporary break within 14 days of your
last day of attendance?

Reason for Leave of Absence : Financial

If Other, explain in detail.

Issues

Acknowledgements
I am requesting a temporary Leave of Absence, and acknowledge that by signing this form I have read
and understand the University Leave of Absence Policy in the Consumer Information Guide
(http://cdn.assets-phoenix.net/content/dam/altcloud/doc/about_uopx/Consumer-Information-Guide.pdf).
I will return to class on or before the return date listed above.
Student Signature

Date

SHANE DAHLQUIST

1/12/2015

This document may be submitted electronically by going to the My Financial Aid Documents section on the Financial
Aid Website at faw .phoenix.edu or fax this document to 480-598-4381.
SFS-O
cc: Student File

FA36

V4 10/09/2013