You are on page 1of 1

University Registrars Office

Lower Level, Warner Hall 5000 Forbes Avenue Pittsburgh, PA 15213-3890 Phone: 412-268-8250 Fax: 412-268-6651 university-registrars-office@andrew.cmu.edu http://www.cmu.edu/hub

Complete this form if you intend to take a leave of absence from Carnegie Mellon. Read the policy on the following pages prior to completing this form. Prior to leaving, you must contact your academic advisor. A leave of absence may jeopardize your financial aid status, contact The HUB for details. Federal law mandates students on F1 or J1 Visa contact the Office of International Education prior to taking a leave of absence.

Leave of Absence
STUDENT INFORMATION
Student Andrew ID: Student Name: Permanent Address:
Last/Family

- OR -

Student ID Card Number:


First and/or Preferred MI

Current Address:

Telephone #: Home College:

Mobile Phone #:

Personal E-Mail Address: Class: Summer-2 If yes, who? 20


Name

Department: Fall Spring Summer-1/All

Semester of Leave (circle one):

Have you consulted with a university official regarding your return? Yes No Students Signature:

Date:

LEAVE OF ABSENCE INFORMATION


Students Reasons for Leave: Expected Semester/Year of Return (circle one): Fall Spring Summer-1/All Summer-2 20

DEPARTMENT INFORMATION & SIGNATURES


Comments/Requirements Governing Return:

Date Student Began Leave Procedure: Advisor:


Required for All Students Print Name

/ Signature:

W Grade(s) Assigned?

Yes Date:

No

Dept. Head:

Graduate Students Only

Print Name Print Name

Signature: Signature:

Date: Date:

Associate Dean:

Undergraduate Students Only

DEAN OF STUDENT AFFAIRS


Comments/Requirements: Dean of Student Affairs: LS
Print Name

Signature:

Date:

- Return is conditional upon the Dean of Student Affairs permission.

URO USE ONLY


Semester Units Dropped New Enrollment Status Adjusted Tuition Initials/Date loa 8/11