SCHOLARSHIPS FOR GRADUATE STUDIES - LOCAL 
REQUEST FOR LEAVE OF ABSENCE 
 
SCHOLAR NAME: _______________________________ UNID:  __________________________ 
SHEI NAME:  _____________________________________________________________________ 
DHEI NAME:  _____________________________________________________________________ 
PROGRAM: _____________________________________________________________________ 
 
“As  stipulated  in  CHED  Memorandum Order (CMO) No. 4, s. 2017, Article VI (Terms 
and  Conditions),  the  scholar shall submit a formal request for Leave of Absence to 
the  Commission.  The  scholar  shall  detail  the  reasons  for  and  other  pertinent 
details  regarding  the  request,  attaching  the  endorsement  from  his/her  SHEI,  and 
written approval from his/her DHEI.  
 
Furthermore,  scholars  who  have  been  approved  for  leave  for  the  terms indicated 
shall  not  receive the scholarship privileges of the said terms. The scholarship shall 
be  deemed terminated should the scholar not re-enroll after one (1) academic year 
or after two (2) semesters and one (1) summer.” 
 
 
 
Name of DHEI : ________________________________________________________________ 
Degree Program : ______________________________________________________________ 
Admitted : AY _______________ Term _____________ 
 
 
I  would  like  to  request  for  a  Leave  of  Absence  starting  AY  __________,  Term  ___________  to  AY 
__________,  Term  ___________.  This  covers  _____  regular academic term/s, and _____ special or 
non-regular  term,  and  is  equivalent  to  _____  months.  The  leave  is  due  to: 
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________. 
 
(Attach separate sheet if necessary)  
 
 
 
 
 
________________________________________ 
Name and Signature of the Scholar and Date Signed 
 
 
 
 
 
 
 
 
 
 

 
 
<<LETTERHEAD OF DHEI>> 
 
 
J. PROSPERO E. DE VERA III, DPA 
Chairman 
Commission on Higher Education 
4/F, HEDC Building, C.P. Garcia Avenue 
Diliman, Quezon City, 1101 
 
Thru : NELSON G. CAINGHOG 
Director-in-Charge 
Scholarships for Graduate Studies - Local 
 
This  is  to  inform  your  office  that  the  request  of  __________________________,  a  student  of 
(Degree  Program)  _________________________  under  the  CHED  Scholarships  for  Graduate 
Studies Local to request for a leave of absence has been:  
⭘ Approved  
⭘ Disapproved  
 
The  leave  of  absence  will  start  on  AY  __________,  Term  ________  to  AY  __________,  Term 
___________.  This  covers  _____  regular  academic  term/s,  and  _____  special  or  non-regular  term, 
and  is  equivalent  to  _____  months.  The  leave  is  due  to: 
______________________________________________________________________________ 
______________________________________________________________________________
______________________________________________________________________________. 
 
 
 
For your consideration. 
 
Noted by:  
 
Name of Grants Management Officer:  ______________________________________ 

Signature:   ______________________________________ 

Date:   ______________________________________ 
 
 
Name of Dean of College:  ______________________________________ 

Signature:   ______________________________________ 

Date:   ______________________________________ 
 
 
 
 

 
<<LETTERHEAD OF SHEI>> 
 
 
J. PROSPERO E. DE VERA III, DPA 
Chairman 
Commission on Higher Education 
4/F, HEDC Building, C.P. Garcia Avenue 
Diliman, Quezon City, 1101 
 
Thru : NELSON G. CAINGHOG 
Director-in-Charge 
Scholarships for Graduate Studies - Local 
 
This  is  to  inform  your  office  that  the  request  of  ______________________________,  a  student  of 
(Degree  Program)  ____________________________________________  under  the  CHED 
Scholarships for Graduate Studies Local to request for a leave of absence has been:  
⭘ Approved  
⭘ Disapproved  
 
The  leave  of  absence  will  start  on AY ________, Term _______ to AY _________, Term _________. 
This  covers  _____ regular academic term/s, and _____ special or non-regular term, and is equivalent 
to  _____  months.  The  leave  is  due  to:  __________________________________________ 
______________________________________________________________________________
______________________________________________________________________________. 
 
This  is  to  further  certify  that  the  service  obligation  of  the  scholar  shall  likewise  be  adjusted  in 
proportion  to  the  extended  period  as  stated  above  and  in  accordance  with  the  scholar’s  agreement 
with (SHEI) _________________________________. 
 
 
For your consideration. 
 
 
Noted by:  
 
Name of SHEI Coordinator:  ______________________________________ 

Signature:   ______________________________________ 

Date:   ______________________________________ 
 
Name of Head of Institution or Authorized   
Representative:  ______________________________________ 

Position:  ______________________________________ 

Signature:   ______________________________________ 

Date:   ______________________________________