MINDANAO STATE UNIVERSITY
ILIGAN INSTITUTE OF TECHNOLOGY
Document Code No.
FM-MSU-IIT-RGTR-002
OFFICE OF THE REGISTRAR
Revision No.
Effective Date
Page No.
00
02.20.2020
1 of 1
APPLICATION FOR LEAVE OF ABSENCE
1.
Name: ___________________________________________________________________________
Last Name
First Name
M. I.
2.
3.
Student ID No.: ________________ College/School: _____________ Course: _________________
Mailing Address: ____________________________________________________________________
___________________________________________________________________
E-mail address: _________________________________
Contact No.______________________
Semester and Academic Year Last Attended: _____________________________________________
Total Number of Units Taken: ________________
Total Failure (units): ___________
Cumulative GPA: ___________________
Period Covered by Leave of Absence: _____________________________________________
Reason(s) for Leave of Absence:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
5.
4.
5.
6.
7.
8.
________________________________
Student’s Signature over Printed Name
_______________________
Date
Approved
Adviser: ____________________________
Disapproved
Date: ___________
Signature over Printed Name
Chairperson: _________________________
Date: ___________
Signature over Printed Name
Dean: ______________________________
Date: ___________
Signature over Printed Name
Parental/Marital Consent:
Approved:
________________________
Signature over Printed Name
________________ __________
Institute Registrar
Accomplish in 3 copies – for the Registrar, the Department and the Student.
If currently registered, file also a withdrawal form (Form 8: Academic Load Revision Permit) provided that it is done within the withdrawal
period.
A. Bonifacio Avenue, Tibanga, 9200 Iligan City
Website: http://www.msuiit.edu.ph
Telephone Nos: (063)221-4050 to 55 Local 4165,
Tele/fax(063) 223-3794, e-mail:registrar@g.msuiit.edu.ph