THE

GS-LOA 402 (10-2016)

UNIVERSITY
OF RHODE ISLAND
GRADUATE SCHOOL THINK BIG WE DOSM

Application for Leave of Absence

Please see Section 4.30 of the Graduate School Manual for information about the application for a Leave of Absence. The Deadline for
submitting this form corresponds to the last day to add courses as specified by the academic calendar for each semester.

Student Name Today's Date 10/14/16

URI ID Department

Preferred E-mail Program

Student Phone # Specialization

(if applicable)
Effective Date

Leave Requested: Expected re-enrollment:

Semester Year Semester Year
Reason for Requested Leave of Absence

Student: After electronically signing, please save the form in the following format, URIID_Lastname_firstname_LOA.pdf
(ex:1002xxx34_Smith_John_LOA.pdf) and send as an attachment to the Department Chair/Graduate Director.

Student

Department Chair/Graduate Director: Form must be submitted for approval by the Department Chair/Graduate Director. After electronically
signing the form, please save and send as an attachment to the Graduate School at gradforms@etal.uri.edu please copy-in (cc:) the student.
Please write LOA in the subject line.

Department Chair/ Approved Not Approved

Graduate Director

Graduate School Use Only

Notes

Graduate
School Dean

Approved Not Approved