LEAVE OF ABSENCE REQUEST FORM
GRADUATE AND PROFESSIONAL STUDIES PROGRAM
Student Name: Click here to enter text.
Date: Click here to enter text.
Student ID#: Click here to enter text.
Phone #:Click here to enter text.
(best number to contact you)
On the lines provided below, please give a detailed explanation why you are
requesting a Leave of Absence from the GPS Program.Click here to enter text.
Last Date of Attendance: Click here to enter text. Course#: Click here to enter
text.Group: Click here to enter text.
Scheduled Date of Re-Entry: Click here to enter text. Course#: Click here to enter text.
Group: Click here to enter text.
I understand that my request for a leave of absence must be received on or before my
last date of class attendance. If I do not return on or before my approved re-entry date, I
will be withdrawn from the program. For Title IV loan borrowers, failure to return by
approved date of re-entry may result in current loans being canceled and/or prior student
loans entering the repayment period effective the last date of class attendance.
Click here to enter text.
Student Name
Last four digits of SSN
Date
OFFICE USE ONLY:
Signature: ____________________________________________
_________________________
Student Financial Services Counselor
____ APPROVED
_____ DENIED
Date
REASON _________________________________
Return Form to:
MVNU Student Financial Services, 800 Martinsburg Road, Mount Vernon, OH 43050-9500
FAX: (740)399-8682 or E-mail: finaid@mvnu.edu